Your browser doesn't support javascript.
Show: 20 | 50 | 100
Results 1 - 20 de 299
Filter
1.
Monaldi Arch Chest Dis ; 92(1)2021 Aug 12.
Article | MEDLINE | ID: covidwho-1822487

ABSTRACT

A pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 was declared in 2020. Severe cases were characterized by the development of acute hypoxemic respiratory failure (AHRF) requiring advanced respiratory support. However, intensive care units (ICU) were saturated, and many patients had to be treated out of ICU. This case describes a 75-year-old man affected by AHRF due to Coronavirus Disease 2019 (COVID-19), hospitalized in a high-dependency unit, with PaO2/FiO2 <100 for 28 consecutive days. An experienced team with respiratory physiotherapists was in charge of the noninvasive ventilatory support (NIVS). The patient required permanent NIVS with continuous positive airway pressure, non-invasive ventilation, high flow nasal oxygen and body positioning. He was weaned from NIVS after 37 days and started exercise training afterwards. The patient was discharged at home with low-flow oxygen therapy. This case represents an example of a successful treatment of AHRF with the still controversial noninvasive respiratory support in one patient with COVID-19.


Subject(s)
COVID-19 , Noninvasive Ventilation , Respiratory Insufficiency , Aged , Humans , Male , Oxygen Inhalation Therapy , Pandemics , Respiratory Insufficiency/etiology , Respiratory Insufficiency/therapy
3.
PLoS Negl Trop Dis ; 16(3): e0010221, 2022 03.
Article in English | MEDLINE | ID: covidwho-1793647

ABSTRACT

Low-cost improvised continuous positive airway pressure (CPAP) device is safe and efficacious in neonatal respiratory distress. There is a great necessity for similar device in adults, and this has been especially made apparent by the recent Coronavirus Disease 2019 (COVID-19) pandemic, which is unmasking the deficiencies of healthcare system in several low-resource countries. We propose a simplified and inexpensive model of improvised CPAP in adults using locally available resources including aquarium air pumps and a novel pressure release mechanism. Although the safety and efficacy of improvised CPAP in adults are not established, the conceptual model we propose has the potential to serve as a lifesaving technology in many low-resource settings during this ongoing pandemic and thus calls for expedited research.


Subject(s)
COVID-19/therapy , Continuous Positive Airway Pressure/instrumentation , Equipment Design/economics , Respiratory Therapy/instrumentation , Adult , Humans , Noninvasive Ventilation/instrumentation , SARS-CoV-2
4.
Chron Respir Dis ; 19: 14799731221081857, 2022.
Article in English | MEDLINE | ID: covidwho-1785081

ABSTRACT

In the last 6 months, home non-invasive ventilation (NIV) services have faced several unanticipated challenges to their effectiveness and delivery as the result of a 'perfect storm' of the COVID-19 pandemic demands. We developed and delivered an innovative follow-up service, to support home NIV delivery, and improve cost-effectiveness and sustainability during COVID-19. Between Feb-2019 and Nov-2020, 92 post-acute patients were issued with home NIV; 25 (27%) out of the 92 patients had unused NIV machines successfully retrieved. The median (IQR) days of home NIV usage were 207 (98) for patients who had their machines returned. All the unused NIV machines retrieved were within the 5-year working life guaranteed by the manufacturer and were all redeployed after appropriate reconditioning and infection control measures. Without the home-visiting and recycling pilot, we would have relied on patients and families to return the unused machines. Given the expected disruption to NIV machine supply for at least the foreseeable 12-18 months, we feel it is important to get this important message out to other home NIV services urgently. Wider implementation of this novel approach could increase the availability of this vital resource and help meet the current demand on home NIV services.


Subject(s)
COVID-19 , Noninvasive Ventilation , Pulmonary Disease, Chronic Obstructive , Respiratory Insufficiency , COVID-19/epidemiology , Humans , Pandemics
5.
Sci Prog ; 105(2): 368504221092891, 2022.
Article in English | MEDLINE | ID: covidwho-1784977

ABSTRACT

Coronavirus disease 2019 (COVID-19) has been declared a pandemic by the World Health Organization; it has affected millions of people and caused hundreds of thousands of deaths. Patients with COVID-19 pneumonia may develop acute hypoxia respiratory failure and require noninvasive respiratory support or invasive respiratory management. Healthcare workers have a high risk of contracting COVID-19 while fitting respiratory devices. Recently, European experts have suggested that the use of helmet continuous positive airway pressure should be the first choice for acute hypoxia respiratory failure caused by COVID-19 because it reduces the spread of the virus in the ambient air. By contrast, in the United States, helmets were restricted for respiratory care before the COVID-19 pandemic until the Food and Drug Administration provided the 'Umbrella Emergency Use Authorization for Ventilators and Ventilator Accessories'. This narrative review provides an evidence-based overview of the use of helmet ventilation for patients with respiratory failure.


Subject(s)
COVID-19 , Noninvasive Ventilation , Respiratory Distress Syndrome , Respiratory Insufficiency , COVID-19/epidemiology , Head Protective Devices/adverse effects , Humans , Hypoxia/complications , Noninvasive Ventilation/adverse effects , Pandemics , Respiratory Insufficiency/epidemiology , Respiratory Insufficiency/etiology , Respiratory Insufficiency/therapy
6.
J Infect Public Health ; 15(3): 349-359, 2022 Mar.
Article in English | MEDLINE | ID: covidwho-1778317

ABSTRACT

BACKGROUND: Noninvasive ventilation (NIV) is beneficial in exacerbations of chronic obstructive pulmonary disease (COPD), but its effectiveness in pneumonia-associated respiratory failure is still controversial. In the current meta-analysis, we aimed to investigate whether the use of NIV before intubation in pneumonia improves the mortality and intubation rates of respiratory failure as compared to no use of NIV in adults. METHODS: We searched three databases from inception to December 2019. We included studies, in which pneumonia patients were randomized initially into either NIV-treated or non-NIV-treated groups. Five full-text publications, including 121 patients, reported eligible data for statistical analysis. RESULTS: With NIV the overall hospital mortality rate seemed lower in patients with pneumonia-associated respiratory failure, but this was not significant [odds ratio (OR) = 0.39; 95% confidence interval (CI): 0.13-1.14; P = 0.085]. In the intensive care unit, the mortality was significantly lower when NIV was applied compared to no NIV treatment (OR = 0.22; 95% CI: 0.07-0.75; P = 0.015). NIV also decreased mortality compared to no NIV in patient groups, which did not exclude patients with COPD (OR = 0.25; 95% CI: 0.08-0.74; P = 0.013). The need for intubation was significantly reduced in NIV-treated patients (OR = 0.22; 95% CI: 0.09-0.53; P = 0.001), which effect was more prominent in pneumonia patient groups not excluding patients with pre-existing COPD (OR = 0.13; 95% CI: 0.03-0.46; P = 0.002). CONCLUSION: NIV markedly decreases the death rate in the intensive care unit and reduces the need for intubation in patients with pneumonia-associated respiratory failure. The beneficial effects of NIV seem more pronounced in populations that include patients with COPD. Our findings suggest that NIV should be considered in the therapeutic guidelines of pneumonia, given that future clinical trials confirm the results of our meta-analysis. AVAILABILITY OF DATA AND MATERIALS: All data and materials generated during the current study are available from the corresponding author on reasonable request.


Subject(s)
Noninvasive Ventilation , Pneumonia , Respiratory Insufficiency , Adult , Hospital Mortality , Humans , Noninvasive Ventilation/methods , Pneumonia/complications , Pneumonia/therapy , Randomized Controlled Trials as Topic , Respiration, Artificial/methods , Respiratory Insufficiency/etiology , Respiratory Insufficiency/therapy
7.
Eur Rev Med Pharmacol Sci ; 26(6): 2165-2170, 2022 Mar.
Article in English | MEDLINE | ID: covidwho-1776795

ABSTRACT

OBJECTIVE: There has been an increase in intensive care applications due to respiratory failure of COVID-19 infection. Management of respiratory failure includes a range of additional interventions, including high-flow nasal oxygen, noninvasive and invasive ventilation and prone position. These interventions contain risk factors for the development of ocular complications. This study aimed to elucidate the ocular pathologies that occurred in COVID-19 patients hospitalized in the intensive care unit. PATIENTS AND METHODS: Patients who completed 24 hours in the intensive care unit were included in the study. Age, gender, duration of hospitalization before intensive care unit, comorbid diseases and APACHE 2 scores of COVID-19 patients admitted to intensive care unit were recorded. SOFA scores, presence of sedation and muscle relaxant, oxygen therapy (conventional oxygen therapy, high flow nasal oxygen therapy, noninvasive ventilation, invasive ventilation) and presence of prone position were recorded. All patients were evaluated daily for ocular findings. Routine eye care protocol was applied to all patients. RESULTS: Seventy patients were followed for a total of 596 days in the intensive care unit. Pathological ocular findings were observed during hospitalization in 59 of the patients followed. The incidence of chemosis in patients who underwent IMV was significantly higher compared to other methods (p<0.001). CONCLUSIONS: In this study, we observed that despite our routine eye care protocols, invasive mechanical ventilation applications predispose corneal surface damage in patients followed up in the intensive care unit with COVID-19 infection.


Subject(s)
COVID-19 , Noninvasive Ventilation , COVID-19/therapy , Critical Care , Humans , Intensive Care Units , Noninvasive Ventilation/methods , Respiration, Artificial/methods , SARS-CoV-2 , Turkey/epidemiology
9.
Med Klin Intensivmed Notfmed ; 117(3): 177-186, 2022 Apr.
Article in German | MEDLINE | ID: covidwho-1763329

ABSTRACT

Treatment of coronavirus disease 2019 (COVID-19) is particularly challenging due to the rapid scientific advances and the often significant hypoxemia. Use of high-flow oxygen, noninvasive mask ventilation, and the technique of awake proning can sometimes avoid the need for intubation. Mechanical ventilation follows the principles of ventilation for acute respiratory distress syndrome (ARDS; lung protective ventilation) and is generally supplemented by consequent positioning therapy (with at least 16 h in prone position in multiple cycles). Antiviral therapy options such as remdesivir usually come too late for patients with COVID-19 in the ICU, the only exception being the administration of monoclonal antibodies for patients without seroconversion. The value of immunomodulatory therapy such as dexamethasone is undisputed. Interleukin­6 antagonists, on the other hand, are rather problematic for ICU patients, and for Janus kinase inhibitors, data and experience are still insufficient in this context.


Subject(s)
COVID-19 , Noninvasive Ventilation , Humans , Intensive Care Units , Noninvasive Ventilation/methods , Prone Position , Respiration, Artificial
11.
Ther Adv Respir Dis ; 16: 17534666221087847, 2022.
Article in English | MEDLINE | ID: covidwho-1759662

ABSTRACT

BACKGROUND: During the novel coronavirus disease 2019 (COVID-19) pandemic raging around the world, the effectiveness of respiratory support treatment has dominated people's field of vision. This study aimed to compare the effectiveness and value of high-flow nasal cannula (HFNC) with noninvasive ventilation (NIV) for COVID-19 patients. METHODS: A comprehensive systematic review via PubMed, Web of Science, Cochrane, Scopus, WHO database, China Biology Medicine Disc (SINOMED), and China National Knowledge Infrastructure (CNKI) databases was conducted, followed by meta-analysis. RevMan 5.4 was used to analyze the results and risk of bias. The primary outcome is the number of deaths at day 28. The secondary outcomes are the occurrence of invasive mechanical ventilation (IMV), the number of deaths (no time-limited), length of intensive care unit (ICU) and hospital stay, ventilator-free days, and oxygenation index [partial pressure of arterial oxygen (PaO2)/fraction of inhaled oxygen (FiO2)] at 24 h. RESULTS: In total, nine studies [one randomized controlled trial (RCT), seven retrospective studies, and one prospective study] totaling 1582 patients were enrolled in the meta-analysis. The results showed that the incidence of IMV, number of deaths (no time-limited), and length of ICU stay were not statistically significant in the HFNC group compared with the NIV group (ps = 0.71, 0.31, and 0.33, respectively). Whereas the HFNC group performed significant advantages in terms of the number of deaths at day 28, length of hospital stay and oxygenation index (p < 0.05). Only in the ventilator-free days did NIV show advantages over the HFNC group (p < 0.0001). CONCLUSION: For COVID-19 patients, the use of HFNC therapy is associated with the reduction of the number of deaths at day 28 and length of hospital stay, and can significantly improve oxygenation index (PaO2/FiO2) at 24 h. However, there was no favorable between the HFNC and NIV groups in the occurrence of IMV. NIV group was superior only in terms of ventilator-free days.


Subject(s)
COVID-19 , Noninvasive Ventilation , Respiratory Insufficiency , COVID-19/therapy , Cannula , Humans , Noninvasive Ventilation/adverse effects , Noninvasive Ventilation/methods , Oxygen Inhalation Therapy/adverse effects , Oxygen Inhalation Therapy/methods , Randomized Controlled Trials as Topic , Respiration, Artificial , Respiratory Insufficiency/therapy
12.
PLoS One ; 17(3): e0265202, 2022.
Article in English | MEDLINE | ID: covidwho-1753195

ABSTRACT

BACKGROUND: Non-invasive ventilation (NIV) has been increasingly used in COVID-19 patients. The limited physiological monitoring and the unavailability of respiratory mechanic measures, usually obtainable during invasive ventilation, is a limitation of NIV for ARDS and COVID-19 patients management. OBJECTIVES: This pilot study was aimed to evaluate the feasibility of non-invasively monitoring respiratory mechanics by oscillometry in COVID-19 patients with moderate-severe acute respiratory distress syndrome (ARDS) receiving NIV. METHOD: 15 COVID-19 patients affected by moderate-severe ARDS at the RICU (Respiratory Intensive Care Unit) of the University hospital of Cattinara, Trieste, Italy were recruited. Patients underwent oscillometry tests during short periods of spontaneous breathing between NIV sessions. RESULTS: Oscillometry proved to be feasible, reproducible and well-tolerated by patients. At admission, 8 of the 15 patients showed oscillometry parameters within the normal range which further slightly improved before discharge. At discharge, four patients had still abnormal respiratory mechanics, not exclusively linked to pre-existing respiratory comorbidities. Lung mechanics parameters were not correlated with oxygenation. CONCLUSIONS: Our results suggest that lung mechanics provide complementary information for improving patients phenotyping and personalisation of treatments during NIV in COVID 19 patients, especially in the presence of respiratory comorbidities where deterioration of lung mechanics may be less coupled with changes in oxygenation and more difficult to identify. Oscillometry may provide a valuable tool for monitoring lung mechanics in COVID 19 patients receiving NIV.


Subject(s)
COVID-19/therapy , Lung/physiopathology , Noninvasive Ventilation/methods , Oscillometry/methods , Respiratory Distress Syndrome/virology , Adult , Aged , COVID-19/physiopathology , Feasibility Studies , Female , Humans , Italy , Male , Middle Aged , Pilot Projects , Respiratory Distress Syndrome/physiopathology , Respiratory Distress Syndrome/therapy , Respiratory Mechanics , Retrospective Studies
13.
Trials ; 23(1): 218, 2022 Mar 18.
Article in English | MEDLINE | ID: covidwho-1745430

ABSTRACT

BACKGROUND: Non-invasive ventilation (NIV) is indicated to avoid orotracheal intubation (OTI) to reduce hospital stay and mortality. Patients infected by SARS-CoV2 can progress to respiratory failure (RF); however, in the initial phase, they can be submitted to oxygen therapy and NIV. Such resources can produce aerosol and can cause a high risk of contagion to health professionals. Safe NIV strategies are sought, and therefore, the authors adapted diving masks to be used as NIV masks (called an Owner mask). OBJECTIVE: To assess the Owner mask safety and effectiveness regarding conventional orofacial mask for patients in respiratory failure with and without confirmation or suspicion of COVID-19. METHODS: A Brazilian multicentric study to assess patients admitted to the intensive care unit regarding their clinical, sociodemographic and anthropometric data. The primary outcome will be the rate of tracheal intubation, and secondary outcomes will include in-hospital mortality, the difference in PaO2/FiO2 ratio and PaCO2 levels, time in the intensive care unit and hospitalization time, adverse effects, degree of comfort and level of satisfaction of the mask use, success rate of NIV (not progressing to OTI), and behavior of the ventilatory variables obtained in NIV with an Owner mask and with a conventional face mask. Patients with COVID-19 and clinical signs indicative of RF will be submitted to NIV with an Owner mask [NIV Owner COVID Group (n = 63)] or with a conventional orofacial mask [NIV orofacial COVID Group (n = 63)], and those patients in RF due to causes not related to COVID-19 will be allocated into the NIV Owner Non-COVID Group (n = 97) or to the NIV Orofacial Non-COVID Group (n = 97) in a randomized way, which will total 383 patients, admitting 20% for loss to follow-up. DISCUSSION: This is the first randomized and controlled trial during the COVID-19 pandemic about the safety and effectiveness of the Owner mask compared to the conventional orofacial mask. Experimental studies have shown that the Owner mask enables adequate sealing on the patient's face and the present study is relevant as it aims to minimize the aerosolization of the virus in the environment and improve the safety of health professionals. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials (ReBEC): RBR - 7xmbgsz . Registered on 15 April 2021.


Subject(s)
COVID-19 , Diving , Noninvasive Ventilation , Humans , Noninvasive Ventilation/adverse effects , Noninvasive Ventilation/methods , Pandemics/prevention & control , RNA, Viral , Randomized Controlled Trials as Topic , SARS-CoV-2
14.
Monaldi Arch Chest Dis ; 92(1)2021 Aug 12.
Article in English | MEDLINE | ID: covidwho-1744832

ABSTRACT

A pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 was declared in 2020. Severe cases were characterized by the development of acute hypoxemic respiratory failure (AHRF) requiring advanced respiratory support. However, intensive care units (ICU) were saturated, and many patients had to be treated out of ICU. This case describes a 75-year-old man affected by AHRF due to Coronavirus Disease 2019 (COVID-19), hospitalized in a high-dependency unit, with PaO2/FiO2 <100 for 28 consecutive days. An experienced team with respiratory physiotherapists was in charge of the noninvasive ventilatory support (NIVS). The patient required permanent NIVS with continuous positive airway pressure, non-invasive ventilation, high flow nasal oxygen and body positioning. He was weaned from NIVS after 37 days and started exercise training afterwards. The patient was discharged at home with low-flow oxygen therapy. This case represents an example of a successful treatment of AHRF with the still controversial noninvasive respiratory support in one patient with COVID-19.


Subject(s)
COVID-19 , Noninvasive Ventilation , Respiratory Insufficiency , Aged , Humans , Male , Oxygen Inhalation Therapy , Pandemics , Respiratory Insufficiency/etiology , Respiratory Insufficiency/therapy
16.
Crit Care ; 26(1): 55, 2022 03 07.
Article in English | MEDLINE | ID: covidwho-1731538

ABSTRACT

BACKGROUND: The ratio of partial pressure of arterial oxygen to inspired oxygen fraction (PaO2/FIO2) during invasive mechanical ventilation (MV) is used as criteria to grade the severity of respiratory failure in acute respiratory distress syndrome (ARDS). During the SARS-CoV2 pandemic, the use of PaO2/FIO2 ratio has been increasingly used in non-invasive respiratory support such as high-flow nasal cannula (HFNC) and non-invasive ventilation (NIV). The grading of hypoxemia in non-invasively ventilated patients is uncertain. The main hypothesis, investigated in this study, was that the PaO2/FIO2 ratio does not change when switching between MV, NIV and HFNC. METHODS: We investigated respiratory function in critically ill patients with COVID-19 included in a single-center prospective observational study of patients admitted to the intensive care unit (ICU) at Uppsala University Hospital in Sweden. In a steady state condition, the PaO2/FIO2 ratio was recorded before and after any change between two of the studied respiratory support techniques (i.e., HFNC, NIV and MV). RESULTS: A total of 148 patients were included in the present analysis. We find that any change in respiratory support from or to HFNC caused a significant change in PaO2/FIO2 ratio. Changes in respiratory support between NIV and MV did not show consistent change in PaO2/FIO2 ratio. In patients classified as mild to moderate ARDS during MV, the change from HFNC to MV showed a variable increase in PaO2/FIO2 ratio ranging between 52 and 140 mmHg (median of 127 mmHg). This made prediction of ARDS severity during MV from the apparent ARDS grade during HFNC impossible. CONCLUSIONS: HFNC is associated with lower PaO2/FIO2 ratio than either NIV or MV in the same patient, while NIV and MV provided similar PaO2/FIO2 and thus ARDS grade by Berlin definition. The large variation of PaO2/FIO2 ratio indicates that great caution should be used when estimating ARDS grade as a measure of pulmonary damage during HFNC.


Subject(s)
COVID-19 , Noninvasive Ventilation , Respiratory Distress Syndrome , Respiratory Insufficiency , COVID-19/therapy , Cannula , Critical Illness/therapy , Humans , Noninvasive Ventilation/methods , Oxygen , Oxygen Inhalation Therapy , RNA, Viral , Respiration, Artificial , Respiratory Distress Syndrome/therapy , Respiratory Insufficiency/therapy , SARS-CoV-2
17.
BMC Anesthesiol ; 22(1): 59, 2022 03 04.
Article in English | MEDLINE | ID: covidwho-1724413

ABSTRACT

BACKGROUND: Data on the lung respiratory mechanics and gas exchange in the time course of COVID-19-associated respiratory failure is limited. This study aimed to explore respiratory mechanics and gas exchange, the lung recruitability and risk of overdistension during the time course of mechanical ventilation. METHODS: This was a prospective observational study in critically ill mechanically ventilated patients (n = 116) with COVID-19 admitted into Intensive Care Units of Sechenov University. The primary endpoints were: «optimum¼ positive end-expiratory pressure (PEEP) level balanced between the lowest driving pressure and the highest SpO2 and number of patients with recruitable lung on Days 1 and 7 of mechanical ventilation. We measured driving pressure at different levels of PEEP (14, 12, 10 and 8 cmH2O) with preset tidal volume, and with the increase of tidal volume by 100 ml and 200 ml at preset PEEP level, and calculated static respiratory system compliance (CRS), PaO2/FiO2, alveolar dead space and ventilatory ratio on Days 1, 3, 5, 7, 10, 14 and 21. RESULTS: The «optimum¼ PEEP levels on Day 1 were 11.0 (10.0-12.8) cmH2O and 10.0 (9.0-12.0) cmH2O on Day 7. Positive response to recruitment was observed on Day 1 in 27.6% and on Day 7 in 9.2% of patients. PEEP increase from 10 to 14 cmH2O and VT increase by 100 and 200 ml led to a significant decrease in CRS from Day 1 to Day 14 (p < 0.05). Ventilatory ratio was 2.2 (1.7-2,7) in non-survivors and in 1.9 (1.6-2.6) survivors on Day 1 and decreased on Day 7 in survivors only (p < 0.01). PaO2/FiO2 was 105.5 (76.2-141.7) mmHg in non-survivors on Day 1 and 136.6 (106.7-160.8) in survivors (p = 0.002). In survivors, PaO2/FiO2 rose on Day 3 (p = 0.008) and then between Days 7 and 10 (p = 0.046). CONCLUSION: Lung recruitability was low in COVID-19 and decreased during the course of the disease, but lung overdistension occurred at «intermediate¼ PEEP and VT levels. In survivors gas exchange improvements after Day 7 mismatched CRS. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04445961 . Registered 24 June 2020-Retrospectively registered.


Subject(s)
COVID-19/epidemiology , COVID-19/therapy , Lung/physiopathology , Respiration, Artificial/statistics & numerical data , Respiratory Insufficiency/epidemiology , Aged , COVID-19/physiopathology , Critical Care/methods , Female , Humans , Male , Middle Aged , Noninvasive Ventilation/statistics & numerical data , Positive-Pressure Respiration , Prospective Studies , Respiratory Insufficiency/physiopathology , Respiratory Mechanics , Russia/epidemiology , SARS-CoV-2 , Survival Analysis , Tidal Volume , Treatment Failure
18.
Hosp Pract (1995) ; 50(2): 118-123, 2022 Apr.
Article in English | MEDLINE | ID: covidwho-1713461

ABSTRACT

OBJECTIVES: Patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) frequently present with a febrile illness that may progress to pneumonia and hypoxic respiratory failure. Aerosolized epoprostenol (aEPO) has been evaluated in patients with acute respiratory distress syndrome and refractory hypoxemia. A paucity of literature has assessed the impact of aEPO in patients with SARS-CoV-2 receiving oxygen support with high flow nasal cannula (HFNC). The objective of this study was to evaluate whether aEPO added to HFNC prevents intubation and/or prolong time to intubation compared to controls only treated with HFNC, guided by oxygen saturation goals. METHODS: This was a single-center, retrospective study of adult patients infected with coronavirus 2019 (COVID-19) and admitted to the medical intensive care unit. A total of 60 patients were included. Thirty patients were included in the treatment, and 30 in the control group, respectively. Among patients included in the treatment group, response to therapy was assessed. The need for mechanical ventilation and hospital mortality between responders vs. non-responders was evaluated. RESULTS: The primary outcome of mechanical ventilation was not statistically different between groups. Time from HFNC initiation to intubation was significantly prolonged in the treatment group compared to the control group (5.7 days vs. 2.3 days, P = 0.001). There was no statistically significant difference between groups in mortality or length of stay. Patients deemed responders to aEPO had a lower rate of mechanical ventilation (50% vs 88%, P = 0.025) and mortality (21% vs 63%, P = 0.024), compared with non-responders. CONCLUSION: The utilization of aEPO in COVID-19 patients treated with HFNC is not associated with a reduction in the rate of mechanical ventilation. Nevertheless, the application of this strategy may prolong the time to invasive mechanical ventilation, without affecting other clinical outcomes.


Subject(s)
COVID-19 , Noninvasive Ventilation , Respiratory Insufficiency , Adult , Epoprostenol/therapeutic use , Humans , Hypoxia/drug therapy , Oxygen Inhalation Therapy , Respiratory Insufficiency/therapy , Retrospective Studies , SARS-CoV-2
19.
JAMA Netw Open ; 5(2): e220548, 2022 02 01.
Article in English | MEDLINE | ID: covidwho-1711993

ABSTRACT

Importance: A World Health Organization (WHO) meta-analysis found that tocilizumab was associated with reduced mortality in hospitalized patients with COVID-19. However, uncertainty remains concerning the magnitude of tocilizumab's benefits and whether its association with mortality benefit is similar across respiratory subgroups. Objective: To use bayesian methods to assess the magnitude of mortality benefit associated with tocilizumab and the differences between respiratory support subgroups in hospitalized patients with COVID-19. Design, Setting, and Participants: A bayesian hierarchical reanalysis of the WHO meta-analysis of tocilizumab studies published in 2020 and 2021 was performed. Main results were estimated using weakly informative priors to exert little influence on the observed data. The robustness of these results was evaluated using vague and informative priors. The studies featured in the meta-analysis were randomized clinical tocilizumab trials of hospitalized patients with COVID-19. Only patients receiving corticosteroids were included. Interventions: Usual care plus tocilizumab in comparison with usual care or placebo. Main Outcomes and Measures: All-cause mortality at 28 days after randomization. Results: Among the 5339 patients included in this analysis, most were men, with mean ages between 56 and 66 years. There were 2117 patients receiving simple oxygen only, 2505 receiving noninvasive ventilation (NIV), and 717 receiving invasive mechanical ventilation (IMV) in 15 studies from multiple countries and continents. Assuming weakly informative priors, the overall odds ratios (ORs) for survival were 0.70 (95% credible interval [CrI], 0.50-0.91) for patients receiving simple oxygen only, 0.81 (95% CrI, 0.63-1.03) for patients receiving NIV, and 0.89 (95% CrI, 0.61-1.22) for patients receiving IMV, respectively. The posterior probabilities of any benefit (OR <1) were notably different between patients receiving simple oxygen only (98.9%), NIV (95.5%), and IMV (75.4%). The posterior probabilities of a clinically meaningful association (absolute mortality risk difference >1%) were greater than 95% in patients receiving simple oxygen only and greater than 90% in patients receiving NIV. In contrast, the posterior probability of this clinically meaningful association was only approximately 67% in patients receiving IMV. The probabilities of tocilizumab superiority in the simple oxygen only subgroup compared with the NIV and IMV subgroups were 85% and 90%, respectively. Predictive intervals highlighted that only 72.1% of future tocilizumab IMV studies would show benefit. The conclusions did not change with different prior distributions. Conclusions and Relevance: In this bayesian reanalysis of a previous meta-analysis of 15 studies of hospitalized patients with COVID-19 treated with tocilizumab and corticosteroids, use of simple oxygen only and NIV was associated with a probability of a clinically meaningful mortality benefit from tocilizumab. Future research should clarify whether patients receiving IMV also benefit from tocilizumab.


Subject(s)
Adrenal Cortex Hormones/pharmacology , Antibodies, Monoclonal, Humanized/pharmacology , COVID-19 , Noninvasive Ventilation , Bayes Theorem , COVID-19/drug therapy , COVID-19/mortality , COVID-19/therapy , Humans , Middle Aged , Mortality , Noninvasive Ventilation/methods , Noninvasive Ventilation/statistics & numerical data , Risk Assessment , World Health Organization
20.
JAMA ; 327(6): 546-558, 2022 02 08.
Article in English | MEDLINE | ID: covidwho-1711978

ABSTRACT

Importance: Continuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) have been recommended for acute hypoxemic respiratory failure in patients with COVID-19. Uncertainty exists regarding the effectiveness and safety of these noninvasive respiratory strategies. Objective: To determine whether either CPAP or HFNO, compared with conventional oxygen therapy, improves clinical outcomes in hospitalized patients with COVID-19-related acute hypoxemic respiratory failure. Design, Setting, and Participants: A parallel group, adaptive, randomized clinical trial of 1273 hospitalized adults with COVID-19-related acute hypoxemic respiratory failure. The trial was conducted between April 6, 2020, and May 3, 2021, across 48 acute care hospitals in the UK and Jersey. Final follow-up occurred on June 20, 2021. Interventions: Adult patients were randomized to receive CPAP (n = 380), HFNO (n = 418), or conventional oxygen therapy (n = 475). Main Outcomes and Measures: The primary outcome was a composite of tracheal intubation or mortality within 30 days. Results: The trial was stopped prematurely due to declining COVID-19 case numbers in the UK and the end of the funded recruitment period. Of the 1273 randomized patients (mean age, 57.4 [95% CI, 56.7 to 58.1] years; 66% male; 65% White race), primary outcome data were available for 1260. Crossover between interventions occurred in 17.1% of participants (15.3% in the CPAP group, 11.5% in the HFNO group, and 23.6% in the conventional oxygen therapy group). The requirement for tracheal intubation or mortality within 30 days was significantly lower with CPAP (36.3%; 137 of 377 participants) vs conventional oxygen therapy (44.4%; 158 of 356 participants) (absolute difference, -8% [95% CI, -15% to -1%], P = .03), but was not significantly different with HFNO (44.3%; 184 of 415 participants) vs conventional oxygen therapy (45.1%; 166 of 368 participants) (absolute difference, -1% [95% CI, -8% to 6%], P = .83). Adverse events occurred in 34.2% (130/380) of participants in the CPAP group, 20.6% (86/418) in the HFNO group, and 13.9% (66/475) in the conventional oxygen therapy group. Conclusions and Relevance: Among patients with acute hypoxemic respiratory failure due to COVID-19, an initial strategy of CPAP significantly reduced the risk of tracheal intubation or mortality compared with conventional oxygen therapy, but there was no significant difference between an initial strategy of HFNO compared with conventional oxygen therapy. The study may have been underpowered for the comparison of HFNO vs conventional oxygen therapy, and early study termination and crossover among the groups should be considered when interpreting the findings. Trial Registration: isrctn.org Identifier: ISRCTN16912075.


Subject(s)
COVID-19/complications , Continuous Positive Airway Pressure , Intubation, Intratracheal , Noninvasive Ventilation/methods , Oxygen Inhalation Therapy/methods , Respiratory Insufficiency/therapy , Adult , COVID-19/mortality , Cannula , Female , Hospital Mortality , Humans , Intubation, Intratracheal/statistics & numerical data , Length of Stay , Male , Middle Aged , Respiratory Insufficiency/etiology
SELECTION OF CITATIONS
SEARCH DETAIL