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1.
PLoS One ; 16(12): e0260006, 2021.
Article in English | MEDLINE | ID: covidwho-1581786

ABSTRACT

BACKGROUND: During the early COVID-19 pandemic travel in Uganda was tightly restricted which affected demand for and access to care for pregnant women and small and sick newborns. In this study we describe changes to neonatal outcomes in one rural central Ugandan newborn unit before and during the early phase of the COVID-19 pandemic. METHODS: We report outcomes from admissions captured in an electronic dataset of a well-established newborn unit before (September 2019 to March 2020) and during the early COVID-19 period (April-September 2020) as well as two seasonally matched periods one year prior. We report excess mortality as the percent change in mortality over what was expected based on seasonal trends. FINDINGS: The study included 2,494 patients, 567 of whom were admitted during the early COVID-19 period. During the pandemic admissions decreased by 14%. Patients born outside the facility were older on admission than previously (median 1 day of age vs. admission on the day of birth). There was an increase in admissions with birth asphyxia (22% vs. 15% of patients). Mortality was higher during COVID-19 than previously [16% vs. 11%, p = 0.017]. Patients born outside the facility had a relative increase of 55% above seasonal expected mortality (21% vs. 14%, p = 0.028). During this period patients had decreased antenatal care, restricted transport and difficulty with expenses and support. The hospital had difficulty with maternity staffing and supplies. There was significant community and staff fear of COVID-19. INTERPRETATION: Increased newborn mortality during the early COVID-19 pandemic at this facility was likely attributed to disruptions affecting maternal and newborn demand for, access to and quality of perinatal healthcare. Lockdown conditions and restrictions to public transit were significant barriers to maternal and newborn wellbeing, and require further focus by national and regional health officials.


Subject(s)
COVID-19/epidemiology , Hospitals, Rural/statistics & numerical data , Infant Mortality , Adult , Continuous Positive Airway Pressure/methods , Female , Hospitals, Rural/organization & administration , Humans , Infant , Infant, Newborn , Intensive Care Units, Neonatal/organization & administration , Intensive Care Units, Neonatal/statistics & numerical data , Maternal Age , Patient Admission/statistics & numerical data , Pregnancy , Retrospective Studies , Rural Health/statistics & numerical data , Uganda/epidemiology , Young Adult
2.
PLoS One ; 16(12): e0261113, 2021.
Article in English | MEDLINE | ID: covidwho-1581761

ABSTRACT

BACKGROUND: Complement activation contributes to lung dysfunction in coronavirus disease 2019 (COVID-19). We assessed whether C5 blockade with eculizumab could improve disease outcome. METHODS: In this single-centre, academic, unblinded study two 900 mg eculizumab doses were added-on standard therapy in ten COVID-19 patients admitted from February 2020 to April 2020 and receiving Continuous-Positive-Airway-Pressure (CPAP) ventilator support from ≤24 hours. We compared their outcomes with those of 65 contemporary similar controls. Primary outcome was respiratory rate at one week of ventilator support. Secondary outcomes included the combined endpoint of mortality and discharge with chronic complications. RESULTS: Baseline characteristics of eculizumab-treated patients and controls were similar. At baseline, sC5b-9 levels, ex vivo C5b-9 and thrombi deposition were increased. Ex vivo tests normalised in eculizumab-treated patients, but not in controls. In eculizumab-treated patients respiratory rate decreased from 26.8±7.3 breaths/min at baseline to 20.3±3.8 and 18.0±4.8 breaths/min at one and two weeks, respectively (p<0.05 for both), but did not change in controls. Between-group changes differed significantly at both time-points (p<0.01). Changes in respiratory rate correlated with concomitant changes in ex vivo C5b-9 deposits at one (rs = 0.706, p = 0.010) and two (rs = 0.751, p = 0.032) weeks. Over a median (IQR) period of 47.0 (14.0-121.0) days, four eculizumab-treated patients died or had chronic complications versus 52 controls [HRCrude (95% CI): 0.26 (0.09-0.72), p = 0.010]. Between-group difference was significant even after adjustment for age, sex and baseline serum creatinine [HRAdjusted (95% CI): 0.30 (0.10-0.84), p = 0.023]. Six patients and 13 controls were discharged without complications [HRCrude (95% CI): 2.88 (1.08-7.70), p = 0.035]. Eculizumab was tolerated well. The main study limitations were the relatively small sample size and the non-randomised design. CONCLUSIONS: In patients with severe COVID-19, eculizumab safely improved respiratory dysfunction and decreased the combined endpoint of mortality and discharge with chronic complications. Findings need confirmation in randomised controlled trials.


Subject(s)
Antibodies, Monoclonal, Humanized/therapeutic use , COVID-19/therapy , Continuous Positive Airway Pressure , Aged , Antibodies, Monoclonal, Humanized/administration & dosage , COVID-19/drug therapy , COVID-19/mortality , COVID-19/physiopathology , Case-Control Studies , Complement Membrane Attack Complex/analysis , Female , Humans , Male , Middle Aged , Retrospective Studies , Thrombosis/drug therapy , Treatment Outcome
3.
Intern Med J ; 51(11): 1810-1815, 2021 11.
Article in English | MEDLINE | ID: covidwho-1526370

ABSTRACT

BACKGROUND: COVID-19 long-term sequelae are ill-defined since only a few studies have explored the long-term consequences of this disease so far. AIMS: To evaluate the 6-month respiratory outcome and exercise capacity of COVID-19 acute respiratory failure (ARF) patients treated with continuous positive airway pressure (CPAP) during the first wave of the ongoing COVID-19 pandemic. METHODS: A retrospective observational study included COVID-19 patients with ARF. Interventions included CPAP during hospitalisation and 6-month follow up. Frailty assessment was carried out through frailty index (FI), pO2 /FiO2 during hospitalisation and at follow up, respiratory parameters, 6-min walking test (6MWT) and the modified British Medical Research Council (mMRC) and Borg scale at follow up. RESULTS: More than half of the patients had no dyspnoea according to the mMRC scale. Lower in-hospital pO2 /FiO2 correlated with higher Borg scale levels after 6MWT (ρ 0.27; P 0.04) at the follow-up visit. FI was positively correlated with length of hospitalisation (ρ 0.3; P 0.03) and negatively with the 6MWT distance walked (ρ -0.36; P 0.004). CONCLUSIONS: Robust and frail patients with COVID-19 ARF treated with CPAP outside the intensive care unit setting had good respiratory parameters and exercise capacity at 6-month follow up, although more severe patients had slightly poorer respiratory performance compared with patients with higher PaO2 /FiO2 and lower FI.


Subject(s)
COVID-19 , Respiratory Insufficiency , Continuous Positive Airway Pressure , Exercise Tolerance , Humans , Pandemics , Respiratory Insufficiency/epidemiology , Respiratory Insufficiency/therapy , Retrospective Studies , SARS-CoV-2
4.
Chest ; 160(1): 175-186, 2021 07.
Article in English | MEDLINE | ID: covidwho-1525725

ABSTRACT

BACKGROUND: SARS-CoV-2 aerosolization during noninvasive positive-pressure ventilation may endanger health care professionals. Various circuit setups have been described to reduce virus aerosolization. However, these setups may alter ventilator performance. RESEARCH QUESTION: What are the consequences of the various suggested circuit setups on ventilator efficacy during CPAP and noninvasive ventilation (NIV)? STUDY DESIGN AND METHODS: Eight circuit setups were evaluated on a bench test model that consisted of a three-dimensional printed head and an artificial lung. Setups included a dual-limb circuit with an oronasal mask, a dual-limb circuit with a helmet interface, a single-limb circuit with a passive exhalation valve, three single-limb circuits with custom-made additional leaks, and two single-limb circuits with active exhalation valves. All setups were evaluated during NIV and CPAP. The following variables were recorded: the inspiratory flow preceding triggering of the ventilator, the inspiratory effort required to trigger the ventilator, the triggering delay, the maximal inspiratory pressure delivered by the ventilator, the tidal volume generated to the artificial lung, the total work of breathing, and the pressure-time product needed to trigger the ventilator. RESULTS: With NIV, the type of circuit setup had a significant impact on inspiratory flow preceding triggering of the ventilator (P < .0001), the inspiratory effort required to trigger the ventilator (P < .0001), the triggering delay (P < .0001), the maximal inspiratory pressure (P < .0001), the tidal volume (P = .0008), the work of breathing (P < .0001), and the pressure-time product needed to trigger the ventilator (P < .0001). Similar differences and consequences were seen with CPAP as well as with the addition of bacterial filters. Best performance was achieved with a dual-limb circuit with an oronasal mask. Worst performance was achieved with a dual-limb circuit with a helmet interface. INTERPRETATION: Ventilator performance is significantly impacted by the circuit setup. A dual-limb circuit with oronasal mask should be used preferentially.


Subject(s)
COVID-19 , Continuous Positive Airway Pressure , Disease Transmission, Infectious/prevention & control , Noninvasive Ventilation , Air Filters , Benchmarking/methods , COVID-19/therapy , COVID-19/transmission , Continuous Positive Airway Pressure/adverse effects , Continuous Positive Airway Pressure/instrumentation , Continuous Positive Airway Pressure/methods , Critical Pathways/standards , Critical Pathways/trends , Humans , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Noninvasive Ventilation/adverse effects , Noninvasive Ventilation/instrumentation , Noninvasive Ventilation/methods , Research Design , Respiratory Function Tests/methods , SARS-CoV-2 , Treatment Outcome , Ventilators, Mechanical
5.
Air Med J ; 40(6): 380-384, 2021.
Article in English | MEDLINE | ID: covidwho-1525661

ABSTRACT

The use of oxygen via a heated high-flow nasal cannula (HHFNC) in transport of the adult patient experiencing hypoxemic respiratory failure is an emerging and successful adjunct. Although early intubation was thought to be the safest intervention early in the coronavirus disease 2019 pandemic, what we have learned over the past year was that it would serve the patient best to avoid intubation. We discuss an individual case study of a coronavirus disease 2019-infected patient who required subsequent interfacility air transport to our quaternary care facility. This patient presented to the receiving air medical team on HHFNC. Before January 2021, the capability of this program to transport these patients on HHFNC was not possible because our current ventilation platforms had to be upgraded to include the high-flow option and because of the relative infancy of the HHFNC platforms available for adult air transport. The previously noted approach to not intubate these patients, or to certainly use caution when making the decision to intubate, was not the common theme until late in 2020. Presented in this case discussion will be pertinent positive and negatives as they relate to transporting the patient on HHFNC to include the all-important issue of oxygen supply and demand. The authors would emphasize that the named products in this case are simply products used by the receiving air medical program and do not in any way support an endorsement of these products over any other platforms used to provide positive patient interventions and outcomes.


Subject(s)
COVID-19 , Respiratory Insufficiency , Adult , Cannula , Continuous Positive Airway Pressure , Humans , Oxygen , Oxygen Inhalation Therapy , Respiratory Insufficiency/therapy , SARS-CoV-2
6.
JAMA Netw Open ; 4(11): e2134241, 2021 11 01.
Article in English | MEDLINE | ID: covidwho-1508587

ABSTRACT

Importance: The influence of sleep-disordered breathing (SDB) and sleep-related hypoxemia in SARS-CoV-2 viral infection and COVID-19 outcomes remains unknown. Controversy exists regarding whether to continue treatment for SDB with positive airway pressure given concern for aerosolization with limited data to inform professional society recommendations. Objective: To investigate the association of SDB (identified via polysomnogram) and sleep-related hypoxia with (1) SARS-CoV-2 positivity and (2) World Health Organization (WHO)-designated COVID-19 clinical outcomes while accounting for confounding including obesity, underlying cardiopulmonary disease, cancer, and smoking history. Design, Setting, and Participants: This case-control study was conducted within the Cleveland Clinic Health System (Ohio and Florida) and included all patients who were tested for COVID-19 between March 8 and November 30, 2020, and who had an available sleep study record. Sleep indices and SARS-CoV-2 positivity were assessed with overlap propensity score weighting, and COVID-19 clinical outcomes were assessed using the institutional registry. Exposures: Sleep study-identified SDB (defined by frequency of apneas and hypopneas using the Apnea-Hypopnea Index [AHI]) and sleep-related hypoxemia (percentage of total sleep time at <90% oxygen saturation [TST <90]). Main Outcomes and Measures: Outcomes were SARS-CoV-2 infection and WHO-designated COVID-19 clinical outcomes (hospitalization, use of supplemental oxygen, noninvasive ventilation, mechanical ventilation or extracorporeal membrane oxygenation, and death). Results: Of 350 710 individuals tested for SARS-CoV-2, 5402 (mean [SD] age, 56.4 [14.5] years; 3005 women [55.6%]) had a prior sleep study, of whom 1935 (35.8%) tested positive for SARS-CoV-2. Of the 5402 participants, 1696 were Black (31.4%), 3259 were White (60.3%), and 822 were of other race or ethnicity (15.2%). Patients who were positive vs negative for SARS-CoV-2 had a higher AHI score (median, 16.2 events/h [IQR, 6.1-39.5 events/h] vs 13.6 events/h [IQR, 5.5-33.6 events/h]; P < .001) and increased TST <90 (median, 1.8% sleep time [IQR, 0.10%-12.8% sleep time] vs 1.4% sleep time [IQR, 0.10%-10.8% sleep time]; P = .02). After overlap propensity score-weighted logistic regression, no SDB measures were associated with SARS-CoV-2 positivity. Median TST <90 was associated with the WHO-designated COVID-19 ordinal clinical outcome scale (adjusted odds ratio, 1.39; 95% CI, 1.10-1.74; P = .005). Time-to-event analyses showed sleep-related hypoxia associated with a 31% higher rate of hospitalization and mortality (adjusted hazard ratio, 1.31; 95% CI, 1.08-1.57; P = .005). Conclusions and Relevance: In this case-control study, SDB and sleep-related hypoxia were not associated with increased SARS-CoV-2 positivity; however, once patients were infected with SARS-CoV-2, sleep-related hypoxia was an associated risk factor for detrimental COVID-19 outcomes.


Subject(s)
COVID-19 , Cause of Death , Hospitalization , Severity of Illness Index , Sleep Apnea Syndromes/complications , Aged , COVID-19/complications , COVID-19/mortality , COVID-19/therapy , Case-Control Studies , Continuous Positive Airway Pressure , Delivery of Health Care, Integrated , Extracorporeal Membrane Oxygenation , Female , Florida , Hospital Mortality , Humans , Hypoxia , Logistic Models , Male , Middle Aged , Odds Ratio , Ohio , Respiration, Artificial , Risk Factors , SARS-CoV-2 , Sleep , Sleep Apnea Syndromes/pathology , Sleep Apnea Syndromes/therapy
7.
Arch Dis Child Fetal Neonatal Ed ; 106(6): 627-634, 2021 Nov.
Article in English | MEDLINE | ID: covidwho-1503592

ABSTRACT

OBJECTIVE: To identify risk factors associated with delivery room respiratory support in at-risk infants who are initially vigorous and received delayed cord clamping (DCC). DESIGN: Prospective cohort study. SETTING: Two perinatal centres in Melbourne, Australia. PATIENTS: At-risk infants born at ≥35+0 weeks gestation with a paediatric doctor in attendance who were initially vigorous and received DCC for >60 s. MAIN OUTCOME MEASURES: Delivery room respiratory support defined as facemask positive pressure ventilation, continuous positive airway pressure and/or supplemental oxygen within 10 min of birth. RESULTS: Two hundred and ninety-eight infants born at a median (IQR) gestational age of 39+3 (38+2-40+2) weeks were included. Cord clamping occurred at a median (IQR) of 128 (123-145) s. Forty-four (15%) infants received respiratory support at a median of 214 (IQR 156-326) s after birth. Neonatal unit admission for respiratory distress occurred in 32% of infants receiving delivery room respiratory support vs 1% of infants who did not receive delivery room respiratory support (p<0.001). Risk factors independently associated with delivery room respiratory support were average heart rate (HR) at 90-120 s after birth (determined using three-lead ECG), mode of birth and time to establish regular cries. Decision tree analysis identified that infants at highest risk had an average HR of <165 beats per minute at 90-120 s after birth following caesarean section (risk of 39%). Infants with an average HR of ≥165 beats per minute at 90-120 s after birth were at low risk (5%). CONCLUSIONS: We present a clinical decision pathway for at-risk infants who may benefit from close observation following DCC. Our findings provide a novel perspective of HR beyond the traditional threshold of 100 beats per minute.


Subject(s)
Critical Pathways/standards , Delivery, Obstetric , Electrocardiography/methods , Oxygen Inhalation Therapy , Umbilical Cord , Australia/epidemiology , Cesarean Section/adverse effects , Cesarean Section/methods , Clinical Decision-Making , Constriction , Continuous Positive Airway Pressure/methods , Delivery, Obstetric/adverse effects , Delivery, Obstetric/methods , Delivery, Obstetric/statistics & numerical data , Female , Gestational Age , Heart Rate , Humans , Infant, Newborn , Male , Monitoring, Physiologic/methods , Oxygen Inhalation Therapy/adverse effects , Oxygen Inhalation Therapy/instrumentation , Oxygen Inhalation Therapy/methods , Risk Assessment/methods , Risk Factors , Time-to-Treatment/standards , Time-to-Treatment/statistics & numerical data
9.
PLoS One ; 16(10): e0258754, 2021.
Article in English | MEDLINE | ID: covidwho-1477539

ABSTRACT

Continuous positive airway pressure (CPAP) has been successfully applied to patients with COVID-19 to prevent endotracheal intubation. However, experience of CPAP application in pregnant women with acute respiratory failure (ARF) due to SARS-CoV-2 pneumonia is scarce. This study aimed to describe the natural history and outcome of ARF in a cohort of pregnant women with SARS-CoV-2 pneumonia, focusing on the feasibility of helmet CPAP (h-CPAP) application and the variables related to ARF worsening. A retrospective, observational study enrolling 41 consecutive pregnant women hospitalised for SARS-CoV-2 pneumonia in a tertiary care center between March 2020 and March 2021. h-CPAP was applied if arterial partial pressure of oxygen to fraction of inspired oxygen ratio (PaO2/FiO2) was inferior to 200 and/or patients had respiratory distress despite adequate oxygen supplementation. Characteristics of patients requiring h-CPAP vs those in room air or oxygen only were compared. Twenty-seven (66%) patients showed hypoxemic ARF requiring oxygen supplementation and h-CPAP was needed in 10 cases (24%). PaO2/FiO2 was significantly improved during h-CPAP application. The device was well-tolerated in all cases with no adverse events. Higher serum C reactive protein and more extensive (≥3 lobes) involvement at chest X-ray upon admission were observed in the h-CPAP group. Assessment of temporal distribution of cases showed a substantially increased rate of CPAP requirement during the third pandemic wave (January-March 2021). In conclusion, h-CPAP was feasible, safe, well-tolerated and improved oxygenation in pregnant women with moderate-to-severe ARF due to SARS-CoV-2 pneumonia. Moderate-to-severe ARF was more frequently observed during the third pandemic wave.


Subject(s)
COVID-19 , Continuous Positive Airway Pressure , Oxygen/administration & dosage , Pregnancy Complications, Infectious , Respiratory Insufficiency , SARS-CoV-2/metabolism , Tertiary Care Centers , Acute Disease , Adult , COVID-19/blood , COVID-19/therapy , Female , Humans , Oxygen/blood , Pregnancy , Pregnancy Complications, Infectious/blood , Pregnancy Complications, Infectious/therapy , Protein C/metabolism , Respiratory Insufficiency/blood , Respiratory Insufficiency/therapy , Retrospective Studies
11.
BMJ Open Respir Res ; 8(1)2021 09.
Article in English | MEDLINE | ID: covidwho-1408531

ABSTRACT

BACKGROUND: NHS England recommends non-invasive continuous positive airway pressure (CPAP) as a possible treatment for type 1 respiratory failure associated with COVID-19 pneumonitis, either to avoid intubation or as a ceiling of care. However, data assessing this strategy are sparse, especially for the use of CPAP as a ceiling of care, and particularly when delivered outside of a traditional critical care environment. We describe a cohort of patients from Liverpool, UK, who received CPAP on a dedicated respiratory surge unit at the start of the second wave of the COVID-19 pandemic in UK. METHODS: Retrospective cohort analysis of consecutive patients receiving CPAP for the treatment of respiratory failure secondary to COVID-19 on the respiratory surge unit at the Royal Liverpool Hospital, Liverpool, UK from 21 September until 30 November 2020. RESULTS: 88 patients were included in the analysis. 56/88 (64%) were deemed suitable for escalation to invasive mechanical ventilation (IMV) and received CPAP as a trial; 32/88 (36%) received CPAP as a ceiling of care. Median age was 63 years (IQR: 56-74) and 58/88 (66%) were men. Median SpO2/FiO2 immediately prior to CPAP initiation was 95 (92-152). Among patients for escalation to IMV, the median time on CPAP was 6 days (IQR 4-7) and survival at day 30 was 84% (47/56) with 14/56 (25%) escalated to IMV. Of those patients for whom CPAP was ceiling of care, the median duration of CPAP was 9 days (IQR 7-11) and 18/32 (56%) survived to day 30. Pulmonary barotrauma occurred in 9% of the cohort. There were no associations found on multivariant analysis that were associated with all-cause 30-day mortality. CONCLUSIONS: With adequate planning and resource redistribution, CPAP may be delivered effectively outside of a traditional critical care setting for the treatment of respiratory failure due to COVID-19. Clinicians delivering CPAP to patients with COVID-19 pneumonitis should be alert to the dangers of pulmonary barotrauma. Among patients who are for escalation of care, the use of CPAP may avoid the need for IMV in some patients. Our data support the NHS England recommendation to consider CPAP as a ceiling of care.


Subject(s)
COVID-19 , Continuous Positive Airway Pressure , Aged , COVID-19/therapy , Critical Care , Female , Humans , Male , Middle Aged , Pandemics , Retrospective Studies , United Kingdom/epidemiology
12.
Curr Opin Pulm Med ; 27(6): 529-534, 2021 11 01.
Article in English | MEDLINE | ID: covidwho-1371768

ABSTRACT

PURPOSE OF REVIEW: To evaluate the impact of the COVID-19 pandemic on the care of people with sleep disorders, to explore relationships between OSA and COVID-19, and to describe current knowledge of the effect of the pandemic on sleep globally. RECENT FINDINGS: COVID-19 has led to significant changes in the practice of sleep medicine, including the care of patients with OSA. An OSA diagnosis may portend a worse prognosis with COVID-19, whilst prior COVID-19 may have an impact on sleep breathing. SUMMARY: The pandemic has caused marked difficulties with access to diagnostic sleep studies and reduced capacity for CPAP initiation. Conversely, adherence to CPAP therapy may have improved, and use of remote consultations and telemonitoring has increased. An OSA diagnosis may be associated with increased risk of severe COVID-19, although any apparent relationship may be attributable to confounding factors, such as obesity and metabolic disease. Small studies have reported some increase in CPAP requirements in OSA patients following COVID-19 infection. More generally, the pandemic has been associated with a deterioration in subjective sleep quality across the population; much of this appears because of increased anxiety and stress. Finally, studies assessing putative links between COVID-19 and REM sleep issues are ongoing.


Subject(s)
COVID-19 , Sleep Apnea, Obstructive , Continuous Positive Airway Pressure , Humans , Pandemics , SARS-CoV-2 , Sleep , Sleep Apnea, Obstructive/epidemiology , Sleep Apnea, Obstructive/therapy
13.
Anaesth Intensive Care ; 49(4): 268-274, 2021 Jul.
Article in English | MEDLINE | ID: covidwho-1341368

ABSTRACT

The use of high flow nasal oxygen in the care of COVID-19-positive adult patients remains an area of contention. Early guidelines have discouraged the use of high flow nasal oxygen therapy in this setting due to the risk of viral spread to healthcare workers. However, there is the need to balance the relative risks of increased aerosol generation and virus transmission to healthcare workers against the role high flow nasal oxygen has in reducing hypoxaemia when managing the airway in high-risk patients during intubation or sedation procedures. The authors of this article undertook a narrative review to present results from several recent papers. Surrogate outcome studies suggest that the risk of high flow nasal oxygen in dispersing aerosol-sized particles is probably not as great as first perceived. Smoke laser-visualisation experiments and particle counter studies suggest that the generation and dispersion of bio-aerosols via high flow nasal oxygen with flow rates up to 60 l/min is similar to standard oxygen therapies. The risk appears to be similar to oxygen supplementation via a Hudson mask at 15 l/min and significantly less than low flow nasal prong oxygen 1-5 l/min, nasal continuous positive airway pressure with ill-fitting masks, bilevel positive airway pressure, or from a coughing patient. However, given the limited safety data, we recommend a cautious approach. For intubation in the COVID-positive or suspected COVID-positive patient we support the use of high flow nasal oxygen to extend time to desaturation in the at-risk groups, which include the morbidly obese, those with predicted difficult airways and patients with significant hypoxaemia, ensuring well-fitted high flow nasal oxygen prongs with staff wearing full personal protective equipment. For sedation cases, we support the use of high flow nasal oxygen when there is an elevated risk of hypoxaemia (e.g. bariatric endoscopy or prone-positioned procedures), but recommend securing the airway with a cuffed endotracheal tube for the longer duration procedures when theatre staff remain in close proximity to the upper airway, or considering the use of a surgical mask to reduce the risk of exhaled particle dispersion.


Subject(s)
COVID-19 , Obesity, Morbid , Adult , Continuous Positive Airway Pressure , Expert Testimony , Humans , Oxygen , SARS-CoV-2
14.
Respir Med ; 187: 106550, 2021 10.
Article in English | MEDLINE | ID: covidwho-1331211

ABSTRACT

INTRODUCTION: In COVID-19 associated hypoxemic acute respiratory failure (ARF) without mandatory indication for urgent endotracheal intubation, a trial of CPAP may be considered. We aimed to evaluate HACOR (heart rate, acidosis, consciousness, oxygenation, respiratory rate) score performance in these patients as predictor of CPAP failure. METHODS: Prospective observational multicentric study (three centers in different countries), including adult patients with SARS-CoV-2 pneumonia admitted to a respiratory intermediate care unit, presenting PaO2/FiO2 < 300 and PaCO2 < 45 mmHg, who received CPAP. One hour after starting CPAP, HACOR was calculated. RESULTS: We enrolled 128 patients, mean age 61,7 years. Mean HACOR at 1 h after starting CPAP was 3,27 ± 3,84 and mean PaO2/FiO2 was 203,30 ± 92,21 mmHg; 35 patients (27,3 %) presented CPAP failure: 29 underwent oro-tracheal intubation and 6 died due to COVID-19 (all having a do-not-intubate order). HACOR accuracy for predicting CPAP failure was 82,03 %, while PaO2/FiO2 accuracy was 81,25 %. CONCLUSION: Although HACOR score had a good diagnostic performance in predicting CPAP failure in COVID-19-related ARF, PaO2/FiO2 has also shown to be a good predictor of failure.


Subject(s)
COVID-19/complications , COVID-19/therapy , Continuous Positive Airway Pressure , Respiratory Insufficiency/therapy , Respiratory Insufficiency/virology , Acidosis , Aged , Blood Gas Analysis , COVID-19/physiopathology , Consciousness , Female , Heart Rate , Humans , Intubation, Intratracheal , Male , Middle Aged , Predictive Value of Tests , Prospective Studies , ROC Curve , Respiratory Insufficiency/diagnosis , Respiratory Rate , Treatment Failure
15.
Crit Care ; 25(1): 268, 2021 07 30.
Article in English | MEDLINE | ID: covidwho-1330231

ABSTRACT

BACKGROUND: Noninvasive respiratory support (NIRS) has been diffusely employed outside the intensive care unit (ICU) to face the high request of ventilatory support due to the massive influx of patients with acute respiratory failure (ARF) caused by coronavirus-19 disease (COVID-19). We sought to summarize the evidence on clinically relevant outcomes in COVID-19 patients supported by NIV outside the ICU. METHODS: We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials register, along with medRxiv and bioRxiv repositories for pre-prints, for observational studies and randomized controlled trials, from inception to the end of February 2021. Two authors independently selected the investigations according to the following criteria: (1) observational study or randomized clinical trials enrolling ≥ 50 hospitalized patients undergoing NIRS outside the ICU, (2) laboratory-confirmed COVID-19, and (3) at least the intra-hospital mortality reported. Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines were followed. Data extraction was independently performed by two authors to assess: investigation features, demographics and clinical characteristics, treatments employed, NIRS regulations, and clinical outcomes. Methodological index for nonrandomized studies tool was applied to determine the quality of the enrolled studies. The primary outcome was to assess the overall intra-hospital mortality of patients under NIRS outside the ICU. The secondary outcomes included the proportions intra-hospital mortalities of patients who underwent invasive mechanical ventilation following NIRS failure and of those with 'do-not-intubate' (DNI) orders. RESULTS: Seventeen investigations (14 peer-reviewed and 3 pre-prints) were included with a low risk of bias and a high heterogeneity, for a total of 3377 patients. The overall intra-hospital mortality of patients receiving NIRS outside the ICU was 36% [30-41%]. 26% [21-30%] of the patients failed NIRS and required intubation, with an intra-hospital mortality rising to 45% [36-54%]. 23% [15-32%] of the patients received DNI orders with an intra-hospital mortality of 72% [65-78%]. Oxygenation on admission was the main source of between-study heterogeneity. CONCLUSIONS: During COVID-19 outbreak, delivering NIRS outside the ICU revealed as a feasible strategy to cope with the massive demand of ventilatory assistance. REGISTRATION: PROSPERO, https://www.crd.york.ac.uk/prospero/ , CRD42020224788, December 11, 2020.


Subject(s)
COVID-19/therapy , Noninvasive Ventilation , Respiratory Distress Syndrome/therapy , COVID-19/mortality , Continuous Positive Airway Pressure , Hospital Mortality , Humans , Intensive Care Units , Intubation/statistics & numerical data , Observational Studies as Topic , Randomized Controlled Trials as Topic , Respiration, Artificial , Respiratory Distress Syndrome/virology
16.
Am J Trop Med Hyg ; 105(3): 727-730, 2021 07 16.
Article in English | MEDLINE | ID: covidwho-1317304

ABSTRACT

Intensive care is expensive, and availability is limited. Low- and middle-income countries in particular have struggled to cope with the large influx of critically ill patients during the COVID-19 pandemic. Noninvasive respiratory support devices delivering continuous positive airways pressure (CPAP) require less resource and staff expertise compared with invasive mechanical ventilators and can be routinely used outside of intensive care units. This study assessed the use of the UCL-Ventura Wayrachi CPAP device in hospitalized patients with COVID-19 in Peru. A secondary analysis of data collected for a feasibility study commissioned by the Peruvian Ministry of Health was conducted. Data were collected from three hospitals, including patient demographics, clinical data, and outcomes. Forty-five patients were enrolled from July 16 to September 1, 2020. Eight patients (18%) were intolerant of the CPAP mask. Of the remainder, 18 (48.7%) improved and were discharged from hospital after 6 days. Eight (21.6%) died while on CPAP and 11 (29.7%) were eventually intubated, of whom two died. In total, 27 (60%) survived to hospital discharge. Participating physicians noted the device was easy to use and provided patient benefit, though voiced concerns about the strain on hospital oxygen supplies. In conclusion, the UCL Ventura Wayrachi CPAP device proved feasible in COVID-19 patients in Peru, and offered a bridging therapy for patients who required a ventilator when none were available.


Subject(s)
COVID-19/therapy , Continuous Positive Airway Pressure , Noninvasive Ventilation , Oxygen/therapeutic use , SARS-CoV-2 , Adult , Aged , Feasibility Studies , Female , Humans , Male , Middle Aged , Young Adult
18.
J Intensive Care Med ; 36(10): 1194-1200, 2021 Oct.
Article in English | MEDLINE | ID: covidwho-1299298

ABSTRACT

BACKGROUND: Airway Pressure Release Ventilation (APRV) is a pressure controlled intermittent mandatory mode of ventilation characterized by prolonged inspiratory time and high mean airway pressure. Several studies have demonstrated that APRV can improve oxygenation and lung recruitment in patients with Acute Respiratory Distress Syndrome (ARDS). Although most patients with COVID-19 meet the Berlin criteria for ARDS, hypoxic respiratory failure due to COVID-19 may differ from traditional ARDS as patients often present with severe, refractory hypoxemia and significant variation in respiratory system compliance. To date, no studies investigating APRV in this patient population have been published. The aim of this study was to evaluate the effectiveness of APRV as a rescue mode of ventilation in critically ill patients diagnosed with COVID-19 and refractory hypoxemia. METHODS: We conducted a retrospective analysis of patients admitted with COVID-19 requiring invasive mechanical ventilation who were treated with a trial of APRV for refractory hypoxemia. PaO2/FIO2 (P/F ratio), ventilatory ratio and ventilation outputs before and during APRV were compared. RESULTS: APRV significantly improved the P/F ratio and decreased FIO2 requirements. PaCO2 and ventilatory ratio were also improved. There was an increase in tidal volume per predicted body weight during APRV and a decrease in total minute ventilation. On multivariate analysis, higher inspiratory to expiratory ratio (I: E) and airway pressure were associated with greater improvement in P/F ratio. CONCLUSIONS: APRV may improve oxygenation, alveolar ventilation and CO2 clearance in patients with COVID-19 and refractory hypoxemia. These effects are more pronounced with higher airway pressure and inspiratory time.


Subject(s)
COVID-19 , Respiratory Distress Syndrome , Continuous Positive Airway Pressure , Humans , Respiratory Distress Syndrome/therapy , Retrospective Studies , SARS-CoV-2
19.
Chest ; 160(1): 175-186, 2021 07.
Article in English | MEDLINE | ID: covidwho-1298651

ABSTRACT

BACKGROUND: SARS-CoV-2 aerosolization during noninvasive positive-pressure ventilation may endanger health care professionals. Various circuit setups have been described to reduce virus aerosolization. However, these setups may alter ventilator performance. RESEARCH QUESTION: What are the consequences of the various suggested circuit setups on ventilator efficacy during CPAP and noninvasive ventilation (NIV)? STUDY DESIGN AND METHODS: Eight circuit setups were evaluated on a bench test model that consisted of a three-dimensional printed head and an artificial lung. Setups included a dual-limb circuit with an oronasal mask, a dual-limb circuit with a helmet interface, a single-limb circuit with a passive exhalation valve, three single-limb circuits with custom-made additional leaks, and two single-limb circuits with active exhalation valves. All setups were evaluated during NIV and CPAP. The following variables were recorded: the inspiratory flow preceding triggering of the ventilator, the inspiratory effort required to trigger the ventilator, the triggering delay, the maximal inspiratory pressure delivered by the ventilator, the tidal volume generated to the artificial lung, the total work of breathing, and the pressure-time product needed to trigger the ventilator. RESULTS: With NIV, the type of circuit setup had a significant impact on inspiratory flow preceding triggering of the ventilator (P < .0001), the inspiratory effort required to trigger the ventilator (P < .0001), the triggering delay (P < .0001), the maximal inspiratory pressure (P < .0001), the tidal volume (P = .0008), the work of breathing (P < .0001), and the pressure-time product needed to trigger the ventilator (P < .0001). Similar differences and consequences were seen with CPAP as well as with the addition of bacterial filters. Best performance was achieved with a dual-limb circuit with an oronasal mask. Worst performance was achieved with a dual-limb circuit with a helmet interface. INTERPRETATION: Ventilator performance is significantly impacted by the circuit setup. A dual-limb circuit with oronasal mask should be used preferentially.


Subject(s)
COVID-19 , Continuous Positive Airway Pressure , Disease Transmission, Infectious/prevention & control , Noninvasive Ventilation , Air Filters , Benchmarking/methods , COVID-19/therapy , COVID-19/transmission , Continuous Positive Airway Pressure/adverse effects , Continuous Positive Airway Pressure/instrumentation , Continuous Positive Airway Pressure/methods , Critical Pathways/standards , Critical Pathways/trends , Humans , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Noninvasive Ventilation/adverse effects , Noninvasive Ventilation/instrumentation , Noninvasive Ventilation/methods , Research Design , Respiratory Function Tests/methods , SARS-CoV-2 , Treatment Outcome , Ventilators, Mechanical
20.
Am J Mens Health ; 15(3): 15579883211029460, 2021.
Article in English | MEDLINE | ID: covidwho-1288590

ABSTRACT

The objective of the study was to identify symptoms of men presenting for an outpatient urology visit that prompted referral for a Home Sleep Apnea Test (HSAT) to assess for obstructive sleep apnea (OSA) by a single provider. To assess the proportion of patients referred for the HSAT who underwent the test and, out of these patients, the proportion of men diagnosed with sleep apnea, we performed a retrospective chart review of men 18-99 years old seen by a single provider in the Department of Urology referred for an HSAT to evaluate for presenting symptoms. Patients with a prior diagnosis of OSA were excluded. Eighteen patients were identified (mean age at time of referral 51 + SD 13 years). Half of patients reported erectile dysfunction/concerns, 56% reported nocturia, 44% had been diagnosed with testosterone deficiency, and 39% reported low libido. Nearly all (89%) of patients snored, all reported fatigue, 56% were over the age of 50, 44% had a BMI >35, and 78% had hypertension. Twelve patients completed the HSAT, all of whom were diagnosed with OSA for which continuous positive airway pressure (CPAP) therapy was initiated. Men presenting with genitourinary concerns to an outpatient urology clinic may also have OSA. About half of included patients reported genitourinary concerns. Hundred percent of patients who completed their sleep study were diagnosed with OSA. Genitourinary concerns, in addition to signs and symptoms commonly associated with OSA, should prompt consideration of sleep apnea evaluation.


Subject(s)
Home Care Services , Sleep Apnea, Obstructive/diagnosis , Adolescent , Adult , Aged , Aged, 80 and over , COVID-19/epidemiology , COVID-19/prevention & control , Continuous Positive Airway Pressure , Humans , Male , Male Urogenital Diseases/complications , Middle Aged , Pandemics , Retrospective Studies , SARS-CoV-2 , Sleep Apnea, Obstructive/therapy
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