Nocturnal hypoventilation and respiratory muscle/cough weakness in COVID-19 ICU survivors

Background: The impact of severe COVID-19 in nocturnal hypoventilation and respiratory muscles/cough strength is unknown. Aim(s): Characterize respiratory function in post-ICU COVID-19 patients and correlate these findings with COVID-19 associated outcomes. Method(s): Retrospective study with 55 post-ICU COVID-19 patients admitted to a rehabilitation center (RC). Clinical data were collected and patients performed arterial blood gas analysis, nocturnal oxy-capnography, maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP) and peak cough flow (PCF) at admission. Result(s): Mean age was 64.4+/-10.2 years, 39 (70.9%) were male. Co-morbidities were present in 50 (90.9%): 39 (70.9%) hypertension;20 (36.4%) diabetes;3 (5.5%) OSA;1 (1.8%) COPD. None had neuromuscular disorders. Median of ICU length was 25.5 (min 5;max 190) days. Fifty-three (96.4%) needed mechanical and invasive ventilation, 6 (10.9%) ECMO and 22 (40%) tracheostomy (all decannulated before admission to our RC). Eighteen (32.7%) had criteria of nocturnal hypoventilation, 17 (30.9%) inspiratory, 16 (29.1%) expiratory and 17 (30.9%) cough weakness. Sepsis correlated with increased length of ICU stay (p=0.007) and with lower PCF values (p=0.048). Neurologic disfunction was associated with lower minimum SpO2 and more time of SpO2<88% (p=0.032;p=0.035). Renal disfunction was associated with higher values of mean and maximum TcCO2 (p=0.003;p=0.011). Patients with previously diagnosed OSA had higher values of MIP and PCF (p=0.006;p<0.001) at evaluation. Conclusion(s): In COVID-19 ICU survivors, nocturnal hypoventilation, inspiratory/expiratory muscle and cough weakness are common and may have an impact in rehabilitation outcomes.

Teleconsultation in respiratory medicine - A position paper of the Portuguese Pulmonology Society.

The COVID-19 pandemic crisis, among so many social, economic and health problems, also brought new opportunities. The potential of telemedicine to improve health outcomes had already been recognised in the last decades, but the pandemic crisis has accelerated the digital revolution. In 2020, a rapid increase in the use of remote consultations occurred due to the need to reduce attendance and overcrowding in outpatient clinics. However, the benefit of their use extends beyond the pandemic crisis, as an important tool to improve both the efficiency and capacity of future healthcare systems. This article reviews the literature regarding telemedicine and teleconsultation standards and recommendations, collects opinions of Portuguese experts in respiratory medicine and provides guidance in teleconsultation practices for Pulmonologists.

Non-invasive respiratory support paths in hospitalized patients with COVID-19: proposal of an algorithm.

COVID-19 related Acute Respiratory Failure, may be successfully treated with Conventional Oxygen therapy, High Flow Nasal Cannula, Continuous Positive Airway Pressure or Bi-level Positive-Pressure ventilation. Despite the accumulated data in favor of the use of different Non-invasive Respiratory therapies in COVID-19 related Acute Respiratory Failure, it is not fully understood when start, escalate and de-escalate the best respiratory supportive option for the different timing of the disease. Based on the current published experience with Non-invasive Respiratory therapies in COVID-19 related Acute Respiratory Failure, we propose an algorithm in deciding when to start, when to stop and when to wean different NIRT. This strategy may help clinicians in better choosing NIRT during this second COVID-19 wave and beyond.

COVID-19 pandemic and non invasive respiratory management: Every Goliath needs a David. An evidence based evaluation of problems.

BACKGROUND AND AIM: The war against Covid-19 is far from won. This narrative review attempts to describe some problems with the management of Covid-19 induced acute respiratory failure (ARF) by pulmonologists. METHODS: We searched the following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and reviewed the references of retrieved articles for additional studies. The search was limited to the terms: Covid-19 AND: acute respiratory distress syndrome (ARDS), SARS, MERS, non invasive ventilation (NIV), high flow nasal cannula (HFNC), pronation (PP), health care workers (HCW). RESULTS: Protection of Health care workers should be paramount, so full Personal Protective Equipment and Negative pressure rooms are warranted. HFNC alone or with PP could be offered for mild cases (PaO2/FiO2 between 200-300); NIV alone or with PP may work in moderate cases (PaO2/FiO2 between 100-200). Rotation and coupled (HFNC/NIV) strategy can be beneficial. A window of opportunity of 1-2h is advised. If PaO2/FIO2 significantly increases, Respiratory Rate decreases with a relatively low Exhaled Tidal Volume, the non-invasive strategy could be working and intubation delayed. CONCLUSION: Although there is a role for non-invasive respiratory therapies in the context of COVID-19 ARF, more research is still needed to define the balance of benefits and risks to patients and HCW. Indirectly, non invasive respiratory therapies may be of particular benefit in reducing the risks to healthcare workers by obviating the need for intubation, a potentially highly infectious procedure.