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1.
In Vivo ; 34(5): 3029-3032, 2020.
Article in English | MEDLINE | ID: covidwho-740633

ABSTRACT

BACKGROUND/AIM: Reports indicate that coronaviridae may inhibit insulin secretion. In this report we aimed to describe the course of glycemia in critically ill patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. PATIENTS AND METHODS: We studied 36 SARS-CoV-2 patients (with no history of diabetes) in one intensive care unit (ICU). All the patients were admitted for hypoxemic respiratory failure; all but four required mechanical ventilation. The mean (±SD) age of the patients was 64.7 (9.7) years; 27 were men; the mean (±SD) duration of ICU stay was 12.9 (8.3 days). RESULTS: Twenty of 36 patients presented with hyperglycemia; brief intravenous infusions of short-acting insulin were administered in six patients. As of May 29 2020, 11 patients had died (seven with hyperglycemia). In 17 patients the Hyperglycemia Index [HGI; defined as the area under the curve of (hyper)glycemia level*time (h) divided by the total time in the ICU] was <16.21 mg/dl (0.90 mmol/l), whereas in three patients the HGI was ≥16.21 mg/dl (0.90 mol/l) and <32.25 mg/dl (1.79 mmol/l). CONCLUSION: In our series of ICU patients with SARS-CoV-2 infection, and no history of diabetes, a substantial number of patients had hyperglycemia, to a higher degree than would be expected by the stress of critical illness, lending credence to reports that speculated a tentative association between SARS-CoV-2 and hyperglycemia. This finding is important, since hyperglycemia can lead to further infectious complications.


Subject(s)
Coronavirus Infections/therapy , Diabetes Mellitus/therapy , Hyperglycemia/therapy , Insulin/metabolism , Pneumonia, Viral/therapy , Betacoronavirus/pathogenicity , Blood Glucose/metabolism , Coronavirus Infections/complications , Coronavirus Infections/virology , Diabetes Mellitus/genetics , Diabetes Mellitus/virology , Female , Hospitalization , Humans , Hyperglycemia/complications , Hyperglycemia/virology , Intensive Care Units , Male , Middle Aged , Pandemics , Pneumonia, Viral/complications , Pneumonia, Viral/virology , Respiration, Artificial , Respiratory Insufficiency/physiopathology , Respiratory Insufficiency/therapy , Severe Acute Respiratory Syndrome/complications , Severe Acute Respiratory Syndrome/therapy , Severe Acute Respiratory Syndrome/virology
2.
Paediatr Respir Rev ; 35: 3-8, 2020 Sep.
Article in English | MEDLINE | ID: covidwho-716917

ABSTRACT

COVID-19 is a coronavirus responsible for a global pandemic that started in China in December 2019 and has quickly spread to almost all countries. Approximately 2% of cases are diagnosed in children. There is increasing evidence for transmission by asymptomatic or presymptomatic adults and children. The clinical features do not differ from those of other respiratory viral infections, although rare cases manifest an unusual rash involving the digits. Disease is generally mild in children but deaths have been reported. Risk groups for severe disease in children are yet to be delineated. All treatments remain experimental.


Subject(s)
Coronavirus Infections/physiopathology , Cytokine Release Syndrome/physiopathology , Pneumonia, Viral/physiopathology , Respiratory Insufficiency/physiopathology , Antiviral Agents/therapeutic use , Betacoronavirus , Child , Clinical Laboratory Techniques , Coronavirus Infections/diagnosis , Coronavirus Infections/therapy , Coronavirus Infections/transmission , Cytokine Release Syndrome/therapy , Extracorporeal Membrane Oxygenation , Humans , Lung/diagnostic imaging , Lung/physiopathology , Pandemics , Pneumonia, Viral/diagnosis , Pneumonia, Viral/therapy , Pneumonia, Viral/transmission , Respiration, Artificial , Respiratory Insufficiency/therapy , Severity of Illness Index
3.
Anatol J Cardiol ; 24(2): 76-80, 2020 08.
Article in English | MEDLINE | ID: covidwho-694159

ABSTRACT

The pathological consequences of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) are multiple, with interstitial pneumonia and consecutive respiratory failure being the most dangerous clinical manifestations. Timely diagnosis and follow-up of pulmonary involvement need a comprehensive imaging strategy, which includes standard chest X-ray, chest computed tomography and lung ultrasound (LUS). In the last 10 years, LUS has become a useful, bedside and easily reproducible tool for lung examination. In the first part of this review, we present the pathophysiological background, technical principles and practical aspects of LUS in patients with SARS-CoV-2 infection. In the second part, the main echographic findings, their interpretation, and the clinical applications of LUS are overviewed. The review ends with the presentation of our work methodology, illustrated with images recorded from COVID-19 patients in our department.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Pneumonia, Viral/complications , Respiratory Insufficiency/diagnostic imaging , Humans , Pandemics , Point-of-Care Systems , Practice Patterns, Physicians' , Respiratory Insufficiency/complications , Respiratory Insufficiency/physiopathology , Ultrasonography
4.
Emerg Med J ; 37(9): 565-566, 2020 Sep.
Article in English | MEDLINE | ID: covidwho-693760

ABSTRACT

We report the experience of prone ventilation in selected patients treated with helmet non-invasive ventilation (NIV) continuous positive airway pressure (CPAP) for acute respiratory failure in COVID-19 pneumonia. Preliminary results showed an improvement in the PaO2 value and PaO2/FiO2 ratio after 1 hour of prone ventilation. No variation of the lung ultrasound pattern before and after prone ventilation has been detected. At the time of writing, we attempted proning with helmet NIV CPAP in 10 patients. In 4 out of 10 patients, the attempt failed due to lack of compliance of the patient, scarce pain control even with ongoing treatment and refusal by the patient to prone positioning.


Subject(s)
Continuous Positive Airway Pressure/methods , Coronavirus Infections , Noninvasive Ventilation/methods , Pandemics , Pneumonia, Viral , Prone Position , Respiratory Insufficiency , Aged , Betacoronavirus/isolation & purification , Coronavirus Infections/complications , Coronavirus Infections/epidemiology , Coronavirus Infections/physiopathology , Coronavirus Infections/therapy , Emergency Service, Hospital/statistics & numerical data , Female , Humans , Italy/epidemiology , Male , Oxygen Consumption , Oxygen Inhalation Therapy/methods , Patient Positioning , Pneumonia, Viral/complications , Pneumonia, Viral/epidemiology , Pneumonia, Viral/etiology , Pneumonia, Viral/physiopathology , Pneumonia, Viral/therapy , Respiratory Insufficiency/etiology , Respiratory Insufficiency/physiopathology , Respiratory Insufficiency/therapy , Treatment Outcome
5.
Biosci Rep ; 40(8)2020 08 28.
Article in English | MEDLINE | ID: covidwho-690426

ABSTRACT

The new 2019 coronavirus disease (COVID-19), according to the World Health Organization (WHO), has been characterized as a pandemic. As more is being discovered about this virus, we aim to report findings of the complete blood count (CBC) of COVID-19 patients. This would serve in providing physicians with important knowledge on the changes that can be expected from the CBC of mild and normal COVID-19 patients. A total of 208 mild and common patients were admitted at the Dongnan Hospital located in the city of Xiaogan, Hubei, China. The CBCs of these patients, following a confirmed diagnosis of COVID-19, were retrospectively analyzed and a significant P<0.05 was found after a full statistical analysis was conducted using the Statistical Package for the Social Sciences (IBM SPSS). CBC analysis revealed changes in the levels of red blood cells (RBCs), hemoglobin (HGB), hematocrit (HCT), mean corpuscular volume (MCV), and C-reactive protein (CRP). Clinicians should expect similar findings when dealing with the new COVID-19.


Subject(s)
Betacoronavirus/pathogenicity , Coronary Disease/diagnosis , Coronavirus Infections/diagnosis , Diabetes Mellitus/diagnosis , Hypertension/diagnosis , Pneumonia, Viral/diagnosis , Respiratory Insufficiency/diagnosis , Adult , Aged , Asymptomatic Diseases , Blood Cell Count , C-Reactive Protein/metabolism , China/epidemiology , Comorbidity , Coronary Disease/blood , Coronary Disease/epidemiology , Coronary Disease/physiopathology , Coronavirus Infections/blood , Coronavirus Infections/epidemiology , Coronavirus Infections/physiopathology , Diabetes Mellitus/blood , Diabetes Mellitus/epidemiology , Diabetes Mellitus/physiopathology , Erythrocyte Indices , Erythrocytes/pathology , Erythrocytes/virology , Female , Hematocrit , Hemoglobins/metabolism , Humans , Hypertension/blood , Hypertension/epidemiology , Hypertension/physiopathology , Male , Middle Aged , Pandemics , Pneumonia, Viral/blood , Pneumonia, Viral/epidemiology , Pneumonia, Viral/physiopathology , Respiratory Insufficiency/blood , Respiratory Insufficiency/epidemiology , Respiratory Insufficiency/physiopathology , Retrospective Studies , Severity of Illness Index
7.
Monaldi Arch Chest Dis ; 90(2)2020 Jun 23.
Article in English | MEDLINE | ID: covidwho-688266

ABSTRACT

There is a need of consensus about the pulmonary rehabilitation (PR) in patients with COVID-19 after discharge from acute care. To facilitate the knowledge of the evidence and its translation into practice, we developed suggestions based on experts' opinion. A steering committee identified areas and questions sent to experts. Other international experts participated to a RAND Delphi method in reaching consensus and proposing further suggestions. Strong agreement in suggestions was defined when the mean agreement was >7 (1 = no agreement and 9 = maximal agreement). Panelists response rate was >95%. Twenty-three questions from 4 areas: Personnel protection equipment, phenotypes, assessments, interventions, were identified and experts answered with 121 suggestions, 119 of which received high level of concordance. The evidence-based suggestions provide the clinicians with current evidence and clinical experts opinion. This framework can be used to facilitate clinical decision making within the context of the individual patient. Further studies will evaluate the clinical usefulness of these suggestions.


Subject(s)
Coronavirus Infections/rehabilitation , Physical Therapy Modalities , Pneumonia, Viral/rehabilitation , Respiratory Insufficiency/rehabilitation , Respiratory Therapy/methods , Ambulatory Care , Betacoronavirus , Coronavirus Infections/complications , Coronavirus Infections/physiopathology , Delphi Technique , Exercise Test , Humans , Intensive Care Units , Italy , Nutritional Status , Pandemics , Personal Protective Equipment , Pneumonia, Viral/complications , Pneumonia, Viral/physiopathology , Quality of Life , Respiratory Function Tests , Respiratory Insufficiency/etiology , Respiratory Insufficiency/physiopathology , Stress Disorders, Post-Traumatic
8.
Respir Res ; 21(1): 198, 2020 Jul 28.
Article in English | MEDLINE | ID: covidwho-680693

ABSTRACT

The novel coronavirus disease 2019 (COVID-19) pandemic is a global crisis, challenging healthcare systems worldwide. Many patients present with a remarkable disconnect in rest between profound hypoxemia yet without proportional signs of respiratory distress (i.e. happy hypoxemia) and rapid deterioration can occur. This particular clinical presentation in COVID-19 patients contrasts with the experience of physicians usually treating critically ill patients in respiratory failure and ensuring timely referral to the intensive care unit can, therefore, be challenging. A thorough understanding of the pathophysiological determinants of respiratory drive and hypoxemia may promote a more complete comprehension of a patient's clinical presentation and management. Preserved oxygen saturation despite low partial pressure of oxygen in arterial blood samples occur, due to leftward shift of the oxyhemoglobin dissociation curve induced by hypoxemia-driven hyperventilation as well as possible direct viral interactions with hemoglobin. Ventilation-perfusion mismatch, ranging from shunts to alveolar dead space ventilation, is the central hallmark and offers various therapeutic targets.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Hypoxia/etiology , Lung/physiopathology , Oxygen Consumption/physiology , Pandemics , Pneumonia, Viral/complications , Respiratory Insufficiency/complications , Coronavirus Infections/epidemiology , Critical Illness , Humans , Hypoxia/metabolism , Hypoxia/physiopathology , Pneumonia, Viral/epidemiology , Respiratory Insufficiency/metabolism , Respiratory Insufficiency/physiopathology
9.
Subst Use Misuse ; 55(11): 1900-1901, 2020.
Article in English | MEDLINE | ID: covidwho-643514

ABSTRACT

BACKGROUND: Alarms have been raised that COVID-19 may disproportionately affect certain populations with substance use disorders, particularly Opioid Use Disorder (OUD), however warnings have largely focused on social risks such as reduced availability of services. Objectives: This commentary highlights three plausible biological mechanisms for potentially worsened outcomes in patients with OUD who contract COVID-19. Results: Opioid-related respiratory depression may amplify risks of hypoxemia from COVID-19 viral pneumonia. Complex opioid immune modulation may impact host response to COVID-19, though the effect direction and clinical significance are unclear. Drug-drug interactions may affect individuals with OUD who are co-administered medications for OUD and medications for COVID-19, particularly due to cardiac adverse effects. Conclusions/Importance: There are plausible biological mechanisms for potentially worsened outcomes in patients with OUD who contract COVID-19; these mechanisms require further study, and should be considered in individuals with OUD.


Subject(s)
Analgesics, Opioid/adverse effects , Arrhythmias, Cardiac/chemically induced , Coronavirus Infections/complications , Immunocompromised Host/immunology , Opioid-Related Disorders/complications , Pneumonia, Viral/complications , Respiratory Insufficiency/chemically induced , Adaptive Immunity/immunology , Analgesics, Opioid/therapeutic use , Betacoronavirus , Coronavirus Infections/drug therapy , Coronavirus Infections/immunology , Coronavirus Infections/physiopathology , Drug Interactions , Humans , Immunity, Innate/immunology , Methadone/adverse effects , Opioid-Related Disorders/drug therapy , Opioid-Related Disorders/immunology , Pandemics , Pneumonia, Viral/drug therapy , Pneumonia, Viral/immunology , Pneumonia, Viral/physiopathology , Prognosis , Respiratory Insufficiency/physiopathology
10.
BMJ Open Respir Res ; 7(1)2020 07.
Article in English | MEDLINE | ID: covidwho-634563

ABSTRACT

The aim of this case series is to describe and evaluate our experience of continuous positive airway pressure (CPAP) to treat type 1 respiratory failure in patients with COVID-19. CPAP was delivered in negative pressure rooms in the newly repurposed infectious disease unit. We report a cohort of 24 patients with type 1 respiratory failure and COVID-19 admitted to the Royal Liverpool Hospital between 1 April and 30 April 2020. Overall, our results were positive; we were able to safely administer CPAP outside the walls of a critical care or high dependency unit environment and over half of patients (58%) avoided mechanical ventilation and a total of 19 out of 24 (79%) have survived and been discharged from our care.


Subject(s)
Continuous Positive Airway Pressure/methods , Coronavirus Infections , Pandemics , Pneumonia, Viral , Procedures and Techniques Utilization/statistics & numerical data , Respiratory Care Units , Respiratory Insufficiency , Betacoronavirus/isolation & purification , Coronavirus Infections/epidemiology , Coronavirus Infections/physiopathology , Coronavirus Infections/therapy , Critical Pathways/trends , Female , Humans , Male , Medical Records/statistics & numerical data , Middle Aged , Outcome Assessment, Health Care , Oxygen Consumption , Pneumonia, Viral/epidemiology , Pneumonia, Viral/physiopathology , Pneumonia, Viral/therapy , Respiratory Care Units/methods , Respiratory Care Units/organization & administration , Respiratory Insufficiency/etiology , Respiratory Insufficiency/mortality , Respiratory Insufficiency/physiopathology , Respiratory Insufficiency/therapy , Survival Analysis , United Kingdom/epidemiology
11.
BMJ Open Respir Res ; 7(1)2020 07.
Article in English | MEDLINE | ID: covidwho-634533

ABSTRACT

Since the outbreak of COVID-19 in China in December 2019, a pandemic has rapidly developed on a scale that has overwhelmed health services in a number of countries. COVID-19 has the potential to lead to severe hypoxia; this is usually the cause of death if it occurs. In a substantial number of patients, adequate arterial oxygenation cannot be achieved with supplementary oxygen therapy alone. To date, there has been no clear guideline endorsement of ward-based non-invasive pressure support (NIPS) for severely hypoxic patients who are deemed unlikely to benefit from invasive ventilation. We established a ward-based NIPS service for COVID-19 PCR-positive patients, with severe hypoxia, and in whom escalation to critical care for invasive ventilation was not deemed appropriate. A retrospective analysis of survival in these patients was undertaken. Twenty-eight patients were included. Ward-based NIPS for severe hypoxia was associated with a 50% survival in this cohort. This compares favourably with Intensive Care National Audit and Research Centre survival data following invasive ventilation in a less frail, less comorbid and younger population. These results suggest that ward-based NIPS should be considered as a treatment option in an integrated escalation strategy in all units managing respiratory failure secondary to COVID-19.


Subject(s)
Continuous Positive Airway Pressure/methods , Coronavirus Infections , Frailty , Geriatric Assessment/methods , Pandemics , Pneumonia, Viral , Respiratory Care Units , Respiratory Insufficiency , Aged, 80 and over , Betacoronavirus/isolation & purification , Coronavirus Infections/epidemiology , Coronavirus Infections/physiopathology , Coronavirus Infections/therapy , Female , Frailty/diagnosis , Frailty/physiopathology , Frailty/therapy , Humans , Lung/diagnostic imaging , Male , Outcome and Process Assessment, Health Care , Oximetry/methods , Oximetry/statistics & numerical data , Oxygen Consumption , Pneumonia, Viral/epidemiology , Pneumonia, Viral/physiopathology , Pneumonia, Viral/therapy , Respiratory Care Units/methods , Respiratory Care Units/organization & administration , Respiratory Insufficiency/etiology , Respiratory Insufficiency/mortality , Respiratory Insufficiency/physiopathology , Respiratory Insufficiency/therapy , Survival Analysis , Tomography, X-Ray Computed/methods , United Kingdom/epidemiology
12.
J Intensive Care Med ; 35(8): 818-824, 2020 Aug.
Article in English | MEDLINE | ID: covidwho-634271

ABSTRACT

It has been well known for decades that prone positioning (PP) improves oxygenation. However, it has gained widespread acceptance only in the last few years since studies have shown significant survival benefit. Many centers have established prone ventilation in their treatment algorithm for mechanically ventilated patients with severe acute respiratory distress syndrome (ARDS). Physiologically, PP should also benefit awake, non-intubated patients with acute hypoxemic respiratory failure. However, proning in non-intubated (PINI) patients did not gain any momentum until a few months ago when the Coronavirus disease 2019 (COVID-19) pandemic surged. A large number of sick patients overwhelmed the health care system, and many centers faced a dearth of ventilators. In addition, outcomes of patients placed on mechanical ventilation because of COVID-19 infection have been highly variable and often dismal. Hence, increased focus has shifted to using various strategies to prevent intubation, such as PINI. There is accumulating evidence that PINI is a low-risk intervention that can be performed even outside intensive care unit with minimal assistance and may prevent intubation in certain patients with ARDS. It can also be performed safely at smaller centers and, therefore, may reduce the patient transfer to larger institutions that are overwhelmed in the current crisis. We present a case series of 2 patients with acute hypoxemic respiratory failure who experienced significant improvements in oxygenation with PP. In addition, the physiology of PP is described, and concerns such as proning in obese and patient's anxiety are addressed; an educational pamphlet that may be useful for both patients and health care providers is provided.


Subject(s)
Anxiety , Coronavirus Infections , Obesity , Pandemics , Patient Positioning/methods , Pneumonia, Viral , Prone Position/physiology , Respiratory Insufficiency , Adult , Anxiety/physiopathology , Anxiety/prevention & control , Betacoronavirus/isolation & purification , Coronavirus Infections/epidemiology , Coronavirus Infections/metabolism , Coronavirus Infections/physiopathology , Coronavirus Infections/therapy , Humans , Hypoxia/etiology , Hypoxia/therapy , Male , Obesity/epidemiology , Obesity/physiopathology , Oxygen Consumption , Oxygen Inhalation Therapy/methods , Pneumonia, Viral/diagnostic imaging , Pneumonia, Viral/epidemiology , Pneumonia, Viral/etiology , Pneumonia, Viral/metabolism , Pneumonia, Viral/physiopathology , Pneumonia, Viral/psychology , Pneumonia, Viral/therapy , Respiration, Artificial/methods , Respiratory Insufficiency/etiology , Respiratory Insufficiency/physiopathology , Respiratory Insufficiency/psychology , Respiratory Insufficiency/therapy , Treatment Outcome
13.
Respiration ; 99(6): 521-542, 2020.
Article in English | MEDLINE | ID: covidwho-610252

ABSTRACT

Against the background of the pandemic caused by infection with the SARS-CoV-2 virus, the German Respiratory Society has appointed experts to develop therapy strategies for COVID-19 patients with acute respiratory failure (ARF). Here we present key position statements including observations about the pathophysiology of (ARF). In terms of the pathophysiology of pulmonary infection with SARS-CoV-2, COVID-19 can be divided into 3 phases. Pulmonary damage in advanced COVID-19 often differs from the known changes in acute respiratory distress syndrome (ARDS). Two types (type L and type H) are differentiated, corresponding to early- and late-stage lung damage. This differentiation should be taken into consideration in the respiratory support of ARF. The assessment of the extent of ARF should be based on arterial or capillary blood gas analysis under room air conditions, and it needs to include the calculation of oxygen supply (measured from the variables of oxygen saturation, hemoglobin level, the corrected values of Hüfner's factor, and cardiac output). Aerosols can cause transmission of infectious, virus-laden particles. Open systems or vented systems can increase the release of respirable particles. Procedures in which the invasive ventilation system must be opened and endotracheal intubation carried out are associated with an increased risk of infection. Personal protective equipment (PPE) should have top priority because fear of contagion should not be a primary reason for intubation. Based on the current knowledge, inhalation therapy, nasal high-flow therapy (NHF), continuous positive airway pressure (CPAP), or noninvasive ventilation (NIV) can be performed without an increased risk of infection to staff if PPE is provided. A significant proportion of patients with ARF present with relevant hypoxemia, which often cannot be fully corrected, even with a high inspired oxygen fraction (FiO2) under NHF. In this situation, the oxygen therapy can be escalated to CPAP or NIV when the criteria for endotracheal intubation are not met. In ARF, NIV should be carried out in an intensive care unit or a comparable setting by experienced staff. Under CPAP/NIV, a patient can deteriorate rapidly. For this reason, continuous monitoring and readiness for intubation are to be ensured at all times. If the ARF progresses under CPAP/NIV, intubation should be implemented without delay in patients who do not have a "do not intubate" order.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Pneumonia, Viral/complications , Respiration Disorders/therapy , Respiration, Artificial , Acute Disease , Disease Progression , Germany , Humans , Hypoxia/etiology , Pandemics , Patient Acuity , Pneumonia, Viral/etiology , Pneumonia, Viral/therapy , Respiration Disorders/etiology , Respiratory Distress Syndrome, Adult/etiology , Respiratory Distress Syndrome, Adult/therapy , Respiratory Insufficiency/etiology , Respiratory Insufficiency/physiopathology , Respiratory Insufficiency/therapy
14.
Can J Anaesth ; 67(9): 1217-1248, 2020 09.
Article in English | MEDLINE | ID: covidwho-603824

ABSTRACT

PURPOSE: We conducted two World Health Organization-commissioned reviews to inform use of high-flow nasal cannula (HFNC) in patients with coronavirus disease (COVID-19). We synthesized the evidence regarding efficacy and safety (review 1), as well as risks of droplet dispersion, aerosol generation, and associated transmission (review 2) of viral products. SOURCE: Literature searches were performed in Ovid MEDLINE, Embase, Web of Science, Chinese databases, and medRxiv. Review 1: we synthesized results from randomized-controlled trials (RCTs) comparing HFNC to conventional oxygen therapy (COT) in critically ill patients with acute hypoxemic respiratory failure. Review 2: we narratively summarized findings from studies evaluating droplet dispersion, aerosol generation, or infection transmission associated with HFNC. For both reviews, paired reviewers independently conducted screening, data extraction, and risk of bias assessment. We evaluated certainty of evidence using GRADE methodology. PRINCIPAL FINDINGS: No eligible studies included COVID-19 patients. Review 1: 12 RCTs (n = 1,989 patients) provided low-certainty evidence that HFNC may reduce invasive ventilation (relative risk [RR], 0.85; 95% confidence interval [CI], 0.74 to 0.99) and escalation of oxygen therapy (RR, 0.71; 95% CI, 0.51 to 0.98) in patients with respiratory failure. Results provided no support for differences in mortality (moderate certainty), or in-hospital or intensive care length of stay (moderate and low certainty, respectively). Review 2: four studies evaluating droplet dispersion and three evaluating aerosol generation and dispersion provided very low certainty evidence. Two simulation studies and a crossover study showed mixed findings regarding the effect of HFNC on droplet dispersion. Although two simulation studies reported no associated increase in aerosol dispersion, one reported that higher flow rates were associated with increased regions of aerosol density. CONCLUSIONS: High-flow nasal cannula may reduce the need for invasive ventilation and escalation of therapy compared with COT in COVID-19 patients with acute hypoxemic respiratory failure. This benefit must be balanced against the unknown risk of airborne transmission.


Subject(s)
Coronavirus Infections/therapy , Oxygen Inhalation Therapy/methods , Pneumonia, Viral/therapy , Respiratory Insufficiency/therapy , Aerosols , Cannula , Coronavirus Infections/complications , Coronavirus Infections/mortality , Humans , Pandemics , Pneumonia, Viral/complications , Pneumonia, Viral/mortality , Randomized Controlled Trials as Topic , Respiratory Insufficiency/physiopathology , Respiratory Insufficiency/virology
15.
Can J Anaesth ; 67(9): 1217-1248, 2020 09.
Article in English | MEDLINE | ID: covidwho-601844

ABSTRACT

PURPOSE: We conducted two World Health Organization-commissioned reviews to inform use of high-flow nasal cannula (HFNC) in patients with coronavirus disease (COVID-19). We synthesized the evidence regarding efficacy and safety (review 1), as well as risks of droplet dispersion, aerosol generation, and associated transmission (review 2) of viral products. SOURCE: Literature searches were performed in Ovid MEDLINE, Embase, Web of Science, Chinese databases, and medRxiv. Review 1: we synthesized results from randomized-controlled trials (RCTs) comparing HFNC to conventional oxygen therapy (COT) in critically ill patients with acute hypoxemic respiratory failure. Review 2: we narratively summarized findings from studies evaluating droplet dispersion, aerosol generation, or infection transmission associated with HFNC. For both reviews, paired reviewers independently conducted screening, data extraction, and risk of bias assessment. We evaluated certainty of evidence using GRADE methodology. PRINCIPAL FINDINGS: No eligible studies included COVID-19 patients. Review 1: 12 RCTs (n = 1,989 patients) provided low-certainty evidence that HFNC may reduce invasive ventilation (relative risk [RR], 0.85; 95% confidence interval [CI], 0.74 to 0.99) and escalation of oxygen therapy (RR, 0.71; 95% CI, 0.51 to 0.98) in patients with respiratory failure. Results provided no support for differences in mortality (moderate certainty), or in-hospital or intensive care length of stay (moderate and low certainty, respectively). Review 2: four studies evaluating droplet dispersion and three evaluating aerosol generation and dispersion provided very low certainty evidence. Two simulation studies and a crossover study showed mixed findings regarding the effect of HFNC on droplet dispersion. Although two simulation studies reported no associated increase in aerosol dispersion, one reported that higher flow rates were associated with increased regions of aerosol density. CONCLUSIONS: High-flow nasal cannula may reduce the need for invasive ventilation and escalation of therapy compared with COT in COVID-19 patients with acute hypoxemic respiratory failure. This benefit must be balanced against the unknown risk of airborne transmission.


Subject(s)
Coronavirus Infections/therapy , Oxygen Inhalation Therapy/methods , Pneumonia, Viral/therapy , Respiratory Insufficiency/therapy , Aerosols , Cannula , Coronavirus Infections/complications , Coronavirus Infections/mortality , Humans , Pandemics , Pneumonia, Viral/complications , Pneumonia, Viral/mortality , Randomized Controlled Trials as Topic , Respiratory Insufficiency/physiopathology , Respiratory Insufficiency/virology
16.
Can J Anaesth ; 67(9): 1217-1248, 2020 09.
Article in English | MEDLINE | ID: covidwho-598848

ABSTRACT

PURPOSE: We conducted two World Health Organization-commissioned reviews to inform use of high-flow nasal cannula (HFNC) in patients with coronavirus disease (COVID-19). We synthesized the evidence regarding efficacy and safety (review 1), as well as risks of droplet dispersion, aerosol generation, and associated transmission (review 2) of viral products. SOURCE: Literature searches were performed in Ovid MEDLINE, Embase, Web of Science, Chinese databases, and medRxiv. Review 1: we synthesized results from randomized-controlled trials (RCTs) comparing HFNC to conventional oxygen therapy (COT) in critically ill patients with acute hypoxemic respiratory failure. Review 2: we narratively summarized findings from studies evaluating droplet dispersion, aerosol generation, or infection transmission associated with HFNC. For both reviews, paired reviewers independently conducted screening, data extraction, and risk of bias assessment. We evaluated certainty of evidence using GRADE methodology. PRINCIPAL FINDINGS: No eligible studies included COVID-19 patients. Review 1: 12 RCTs (n = 1,989 patients) provided low-certainty evidence that HFNC may reduce invasive ventilation (relative risk [RR], 0.85; 95% confidence interval [CI], 0.74 to 0.99) and escalation of oxygen therapy (RR, 0.71; 95% CI, 0.51 to 0.98) in patients with respiratory failure. Results provided no support for differences in mortality (moderate certainty), or in-hospital or intensive care length of stay (moderate and low certainty, respectively). Review 2: four studies evaluating droplet dispersion and three evaluating aerosol generation and dispersion provided very low certainty evidence. Two simulation studies and a crossover study showed mixed findings regarding the effect of HFNC on droplet dispersion. Although two simulation studies reported no associated increase in aerosol dispersion, one reported that higher flow rates were associated with increased regions of aerosol density. CONCLUSIONS: High-flow nasal cannula may reduce the need for invasive ventilation and escalation of therapy compared with COT in COVID-19 patients with acute hypoxemic respiratory failure. This benefit must be balanced against the unknown risk of airborne transmission.


Subject(s)
Coronavirus Infections/therapy , Oxygen Inhalation Therapy/methods , Pneumonia, Viral/therapy , Respiratory Insufficiency/therapy , Aerosols , Cannula , Coronavirus Infections/complications , Coronavirus Infections/mortality , Humans , Pandemics , Pneumonia, Viral/complications , Pneumonia, Viral/mortality , Randomized Controlled Trials as Topic , Respiratory Insufficiency/physiopathology , Respiratory Insufficiency/virology
18.
ACS Chem Neurosci ; 11(16): 2416-2421, 2020 08 19.
Article in English | MEDLINE | ID: covidwho-618646

ABSTRACT

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been established as a cause of severe alveolar damage and pneumonia in patients with advanced Coronavirus disease (COVID-19). The consolidation of lung parenchyma precipitates the alterations in blood gases in COVID-19 patients that are known to complicate and cause hypoxemic respiratory failure. With SARS-CoV-2 damaging multiple organs in COVID-19, including the central nervous system that regulates the breathing process, it is a daunting task to compute the extent to which the failure of the central regulation of the breathing process contributes to the mortality of COVID-19 affected patients. Emerging data on COVID-19 cases from hospitals and autopsies in the last few months have helped in the understanding of the pathogenesis of respiratory failures in COVID-19. Recent reports have provided overwhelming evidence of the occurrence of acute respiratory failures in COVID-19 due to neurotropism of the brainstem by SARS-CoV-2. In this review, a cascade of events that may follow the alterations in blood gases and possible neurological damage to the respiratory regulation centers in the central nervous system (CNS) in COVID-19 are related to the basic mechanism of respiratory regulation in order to understand the acute respiratory failure reported in this disease. Though a complex metabolic and respiratory dysregulation also occurs with infections caused by SARS-CoV-1 and MERS that are known to contribute toward deaths of the patients in the past, we highlight here the role of systemic dysregulation and the CNS respiratory regulation mechanisms in the causation of mortalities seen in COVID-19. The invasion of the CNS by SARS-CoV-2, as shown recently in areas like the brainstem that control the normal breathing process with nuclei like the pre-Bötzinger complex (pre-BÖTC), may explain why some of the patients with COVID-19, who have been reported to have recovered from pneumonia, could not be weaned from invasive mechanical ventilation and the occurrences of acute respiratory arrests seen in COVID-19. This debate is important for many reasons, one of which is the fact that permanent damage to the medullary respiratory centers by SARS-CoV-2 would not benefit from mechanical ventilators, as is possibly occurring during the management of COVID-19 patients.


Subject(s)
Coronavirus Infections/physiopathology , Hypoxia/physiopathology , Pneumonia, Viral/physiopathology , Respiratory Center/physiopathology , Respiratory Insufficiency/physiopathology , Betacoronavirus , Blood Gas Analysis , Coronavirus Infections/metabolism , Coronavirus Infections/mortality , Humans , Hypoxia/metabolism , Pandemics , Pneumonia, Viral/metabolism , Pneumonia, Viral/mortality , Respiratory Center/metabolism , Respiratory Center/virology , Respiratory Insufficiency/metabolism , Respiratory Insufficiency/mortality , Viral Tropism
20.
Am J Respir Crit Care Med ; 201(12): 1560-1564, 2020 06 15.
Article in English | MEDLINE | ID: covidwho-155108
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