The geriatric perspectives in the time of COVID-19

During the COVID-19 pandemic, the considerable preponderance of deaths is occurring in older persons. The current Italian data, for example, indicate that persons aged 70 years and older contribute to about 85% of the death events [1]. In the scenario of rationing the resources, the differentiation between the causes of death can be difficult. Specifically, to establish if the death of an older patient is due to COVID-19 or the result of treatment limitations can be difficult [2]. The reading of actual pandemic from the geriatric point of view should include different planes: ethical, legal and clinical. © Springer Nature Switzerland AG 2020.

COVID-19: End-of-life care decision-making and preferences in older people

Elderly patients, frail, and with underlying many chronic comorbidities or severe illness are most at risk from COVID-19 pandemic. Recent data from the Italian Istituto Superiore di Sanità (ISS) showed that COVID-19 is more lethal in older subjects. In Italy, on the date of March 17, 2020, the overall case-fatality rate was 7.2%, and 96.4% of died patients had more than 60 years. When age groups stratified data, individuals aged 70 years or older represent 35.5% of cases, while subjects aged ≥80 years were 52.3% [1]. With respect to the severe context of widespread world mortality, the main aims of the palliative care (quality of life, discernment of patient goals, advance care planning, pain and symptom management, and support for caregivers over protracted trajectories) may appear not essential [2]. The COVID-19 pandemic showed, conversely, the limits of the healthcare system on managing elderly patient's wishes even and expectations during the dreadful COVID-19 disease. During epidemic such as that of SARS CoV 2, the necessity of intensive care unit (ICU) beds could be not sufficient for the patients with severe respiratory distress (ARDS). Many recommendations suggest, in these contests, that the physicians should guarantee the healthcare resources to the patients with a higher life expectancy. The evaluation for the need for intensive care should include the severity of the disease, the comorbidity and the presence of multi-organ failure. Have still, in this period, the insight of patient goals such as wishes, advance care planning and even end of life preferences a central value? This chapter would analyse this prerogative in light of the severity of COVID pandemic. © Springer Nature Switzerland AG 2020.

Covid-19 airway management and ventilation strategy for critically ill older patients

This book describes the issues and challenges that clinicians encountered in the management of older critically ill patients during the Covid-19 pandemic, and offers practical information on how to manage them. Older adults are more susceptible to complications such as acute respiratory distress syndrome (ARDS) as a result of viral pneumonia. In addition, they often have multiple comorbidities and are commonly frail, which means their various organs and systems, such as the respiratory system, have reduced functional reserves. As such, older adults are less able to react to acute stressors. During the current Covid-19 pandemic, older adult patients' mortality is increased. Further, the infection and death rates of elderly people in nursing homes and health care institutions are high. Management of older adults with Covid is complicated. The reduced availability of beds may limit their access to ICU. Moreover, the prognosis may be poor, and airway management and ventilation strategies have to take into account various clinical and physiological characteristics specific to older patients. This book is addressed to all allied professionals involved in the management of older critically ill patients and presents information collected and practical lessons learned from the clinical daily management of this population during the pandemic. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020. All rights reserved.

Oxygen therapy: Liberal versus conservative in older patients with COVID disease

The management of acute respiratory failure is more complicated in elderly patients. The reasons behind this difficulty are mainly related to the frailty and the comorbidities. In particular, the frailty is characterised by a decline in physiological capacity across several organ systems, with a resultant increased susceptibility to stressors. In a few words, frailty means diminished organ reserve, including that of the lung. The first step in the management of acute respiratory failure remains to treat hypoxemia with oxygen therapy. The primary rationale of oxygen (O2) therapy is to prevent and correct arterial hypoxaemia (reduction of O2 in the blood) and any resulting hypoxia (the decrease of the O2 in the tissues) in patients with or at risk for impaired pulmonary gas exchange. The hypoxaemia is characterised by the partial pressure of O2 less than 60 mmHg in blood gas analysis or a SaO2 of <90% while breathing in room air [1]. Besides, over the last years, most acute treatment algorithms recommended the liberal use of a high fraction of inspired oxygen, even without first confirming the presence of a hypoxic insult. For example, for more than a century, supplemental oxygen has been used routinely in the treatment of patients with suspected acute myocardial infarction. The use of additional oxygen therapy in acute coronary syndromes (ACS) and cardiac emergencies has demonstrated to be controversial. In 2010, the American Heart Association (AHA) stated that oxygen should be delivered to patients with breathlessness, signs of heart failure, shock, or an arterial oxyhaemoglobin saturation <94% (Class I, LOE C) and not to all patients with ACS. Non-invasive monitoring of blood oxygen saturation can be useful to decide on the need for oxygen administration [2]. In 2015, some data questioned the consolidated clinical use of supplemental oxygen therapy. The Australian Air Versus Oxygen in Myocardial Infarction (AVOID) trial supported an adverse effect of oxygen. The trial reported larger infarct sizes in patients with ST-segment elevation myocardial infarction (STEMI) who received oxygen than in those who did not receive oxygen [3]. The history of oxygen supplementation in ACS is an example of the binary therapeutic option (liberal versus conservative use of oxygen). A Cochrane report from 2016 did not show any evidence supporting the routine use of oxygen in the treatment of patients with myocardial infarction [4]. In the same way for the treatment of stroke, the guidelines have affirmed that oxygen therapy may be harmful if used for non-hypoxemic patients with mild-moderate strokes [5]. Starting from these examples in this chapter, the authors analysed the evidence of oxygen therapy in the treatment of acute critical patients and acute respiratory distress syndrome (ARDS). The authors will investigate the use of oxygen therapy in light of the available physiopathological patterns of acute respiratory failure of COVID-19 disease. © Springer Nature Switzerland AG 2020.

Negative Noninvasive Ventilation-Cuirass: Design and Clinical Implications

The first body ventilator was called, by Philip Drinker and Louis Agassiz Shaw, “iron lung” due to the metal being used in the construction of the tank that contained the patient. However, in the following years, not only were used lighter materials, but were also used different shapes in order to contain the chest of the patients to be treated, and thus, the “pneumowrap” and the “cuirass” were born. Each of these ventilators has particular characteristics and clinical indications that are listed here. A particular note must be added to the Hayek ventilator, which, with its oscillatory wave delivery, has additional characteristics to the normal “cuirass” and the “Double Positive + Negative Synchronized Ventilation (DPNSV)” in which two synchronized ventilators are being used. Each of these acts in a diametrically opposite way on the chest: One delivers a positive pressure to the airways and the other a negative extra-thoracic pressure. With this latest mode of mechanical ventilation, which eliminates alveolar pressures during inspiration, a new path is being opened in treating even difficult patients such as those suffering from ARDS or COVID-19. © 2022 by Nova Science Publishers, Inc. All rights reserved.

Recurrent pneumothorax after cesarean delivery in the critically ill pregnant with severe COVID-19 ARDS: a case report.

OBJECTIVE: Few data are available on the ICU management and on the possible respiratory complications of invasively ventilated pregnant patients affected by COVID-19 pneumonia, especially in the early phase of pregnancy. Tension pneumothorax has been previously described as a rare cause of respiratory failure after delivery, but its occurrence in the postpartum of COVID-19 patient has not been reported yet. We hereby describe the ICU management of a 23rd gestational week pregnant woman who underwent invasive mechanical ventilation, prone positioning, and cesarean delivery during her ICU stay for COVID-19 related pneumonia. Moreover, we focused on the occurrence and management of recurrent tension pneumothorax after the cesarean delivery. CASE REPORT: A 23rd gestational week pregnant woman was admitted to the ICU for a COVID-19 bilateral pneumonia and underwent invasive mechanical ventilation and prone positioning. Cesarean delivery was planned during the ICU stay, while the patient was receiving invasive mechanical ventilation. After delivery, the patient experienced a recurrent pneumothorax that required the positioning of multiple chest drains. CONCLUSIONS: In pregnant critically ill COVID-19 patients, mechanical ventilation management is particularly challenging, especially in the postpartum period. Prone positioning is feasible and can improve oxygenation and respiratory system compliance, while tension pneumothorax must be suspected if the respiratory function suddenly deteriorates after delivery.

Respiratory care in non invasive mechanical ventilatory support: Principles and practice

Non-invasive ventilation refers to the use of breathing support administered through a face mask, nasal mask, or helmet. This form of ventilatory support is useful in the treatment of respiratory illnesses including SARS, MERS, PH1N1, and COVID-19. Consisting of 63 chapters, this book provides a detailed, holistic overview of the principles and practice of non-invasive mechanical ventilatory support. © 2021 by Nova Science Publishers, Inc. All rights reserved.