Clinical characteristics and risk factors of patients with COVID-19 developing barotrauma

Background: At our hospital, people with COVID-19 (coronavirus disease 2019) had a high rate of pulmonary barotrauma. Therefore, the current study looked at barotrauma in COVID-19 patients getting invasive and non-invasive positive pressure ventilation to assess its prevalence, clinical results, and features. Methodology: Our retrospective cohort study comprised of adult COVID-19 pneumonia patients who visited our tertiary care hospital between April 2020 and September 2021 and developed barotrauma. Result(s): Sixty-eight patients were included in this study. Subcutaneous emphysema was the most frequent type of barotrauma, reported at 67.6%;pneumomediastinum, reported at 61.8%;pneumothorax, reported at 47.1%. The most frequent device associated with barotrauma was CPAP (51.5%). Among the 68 patients, 27.9% were discharged without supplemental oxygen, while 4.4% were discharged on oxygen. 76.5% of the patients expired because of COVID pneumonia and its complications. In addition, 38.2% of the patients required invasive mechanical breathing, and 77.9% of the patients were admitted to the ICU. Conclusion(s): Barotrauma in COVID-19 can pose a serious risk factor leading to mortality. Also, using CPAP was linked to a higher risk of barotrauma.Copyright © 2021 Muslim OT et al.

Respiratory support for adult patients with COVID-19

The COVID-19 pandemic is creating unique strains on the healthcare system. While only a small percentage of patients require mechanical ventilation and ICU care, the enormous size of the populations affected means that these critical resources may become limited. A number of non-invasive options exist to avert mechanical ventilation and ICU admission. This is a clinical review of these options and their applicability in adult COVID-19 patients. Summary recommendations include: (1) Avoid nebulized therapies. Consider metered dose inhaler alternatives. (2) Provide supplemental oxygen following usual treatment principles for hypoxic respiratory failure. Maintain awareness of the aerosol-generating potential of all devices, including nasal cannulas, simple face masks, and venturi masks. Use non-rebreather masks when possible. Be attentive to aerosol generation and the use of personal protective equipment. (3) High flow nasal oxygen is preferred for patients with higher oxygen support requirements. Non-invasive positive pressure ventilation may be associated with higher risk of nosocomial transmission. If used, measures special precautions should be used reduce aerosol formation. (4) Early intubation/mechanical ventilation may be prudent for patients deemed likely to progress to critical illness, multi-organ failure, or acute respiratory distress syndrome (ARDS).Copyright © 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.

The Use of Intermittent Non-Invasive Ventilation as an Alveolar Recruitment Method for Patient with Severe COVID-19 Pneumonia

Background: The use of non-invasive ventilation (NIV) as a therapy for acute respiratory distress syndrome (ARDS) secondary to COVID-19 pneumonia has been controversial. NIV is an aerosol generating procedure which may increase the risk of viral transmission amongst patients and staff. Because of fear of aerosolizing the virus and transmitting the disease, initial expert recommendation was to avoid NIV and proceed with early intubation. With further experience of the virus, this recommendation has been challenged and NIV has been used widely with some retrospective studies quoting between 11 to 56 percent of COVID-19 related respiratory failures being treated with NIV. Objective: The objective of this study is to assess the efficacy and safety of using non-invasive mechanical ventilation as an alveolar recruitment method for patients with severe COVID-19 pneumonia. This method was used by our respiratory team on selected patients during the early phase of the COVID-19 pandemic. Methods: We reviewed the charts of patients that were admitted to the American Hospital Dubai intensive care unit, or our medical step-down unit who had diffuse bilateral infiltrates requiring oxygen supplementation between March and October 2020. We identified patients who were on intermittent BiPAP in addition to standard care. We also monitored the rate of infection among staff taking care of these patients. Results: Average length of stay after starting BIPAP therapy was 6.8 days, while the average total length of stay was 13.6 days. Only one patient was transferred to the ICU after being on the BIPAP protocol and did not need intubation. All patients were discharged home either without oxygen or with their chronic baseline home oxygen requirement. Radiological improvement in aeration was seen in 100% of patients at follow-up x-ray post-intervention. There were no reported pulmonary complications from barotrauma, such as pneumothorax or pneumomediastinum. There were no reported cases of staff infection to the health care workers that were taking care of these patients. Conclusion: Our first of its kind observational study showed clearly that using BIPAP therapy for one hour three times daily during nebulization therapy in addition to standard care resulted in a significant reduction in hospital length of stay and hastened the clinical and radiological improvement of patients with severe COVID-19 pneumonia. © 2022 Zouwayhed et al.

Research Using Social Media to Recruit Research Participants Should Proceed With Caution. Comment on “Telemanagement of Home-Isolated COVID-19 Patients Using Oxygen Therapy With Noninvasive Positive Pressure Ventilation and Physical Therapy Techniques: Randomized Clinical Trial”

Related Articles Comment on: https://www.jmir.org/2021/4/e23446 Comment in: https://www.jmir.org/2022/5/e37413/

Authors Reply to: Research Using Social Media to Recruit Research Participants Should Proceed With Caution. Comment on “Telemanagement of Home-Isolated COVID-19 Patients Using Oxygen Therapy With Noninvasive Positive Pressure Ventilation and Physical Therapy Techniques: Randomized Clinical Trial”

Related Articles Comment on: https://www.jmir.org/2022/5/e34437 Comment on: https://www.jmir.org/2021/4/e23446

EMERGENCY BIPAP VENTILATOR FOR BREATHING ASSISTANCE

The paper proposes the concept of a simplified ventilation device that meets the requirements for the South African Health Products Regulatory Authority (SAHPRA) approval and may be manufactured in large n umbers at moderate cost to meet the requirements of the current or future pne umonic type pandemics. The paper further describes the development of such a device and presents descriptions of the final prototype. The philosophy behind the design was to take an engineering view of the problem of safe ventilation, which also meets World H ealth Organisation (WHO) guideline 'Technical specifications for invasive and no n-invasive v entilators for C OVID-19' (2020), whilst using the hum an biological responses t o control the aspiration boundaries, thereby avoiding the very complex processes which simulate the breathing mechanism. The methodology em ployed was a c onceptual d esign ph ase f ollowed by a n engi neering design phase, pr ototyping, testing, and further developments. The concept was based on guidelines from WHO, 2020: Technical specifications for invasive and non-invasive ventilators for COVID-19: Interim guidance: paragraphs 2.1.2 and 2.2.2.(2020) and measured against the UK standard of the Medicines and H ealthcare Products R egulatory Agency (MHPRA) 'Rapidly m anufactured v entilator s ystem' (2020). Each component of the conceptual design was developed in this way and a final prototype was assembled for independent evaluation and eventual SAHPRA evaluation. The finished prototype meets WHO guidelines for a Bi-level Positive Airway Pressure (BiPAP) system and also meets the guideline requirements for portability. The prototype also meets the initial intent regarding simplicity, functionality and cost. The further developments to mass production will reduce the part count a nd as sembly processes, with some components to be reconfigured as di sposable items, not for sterilisation or re-use. The project has shown that specialised equipment may be viewed pragmatically according to the requirement - to treat all breathing difficulties with a full specification ventilator is not possible or necessary;to assist the majority of ostensibly minor cases with a Bi-PAP system is both practical and more affordable. The intent is not to compete with the high technology commercially s ourced eq uipment, or e ven t he r apidly prototyped r e-purposed i ndustrial ef forts worldwide, but rather to initiate some progress in the Republic of South Africa to quickly produce an abundance of these machines, t o cope with the possible deficit of medical ventilators expected i n future. The solution lies in a simple but f ailsafe de vice that provides assisted breathing with the option of oxygen enrichment. It is intended to be locally manufactured with the minimum of skills and is easily maintained and sterilised.

Modified Bain's Circuit as an Alternate to Non-invasive Ventilation in COVID 19.

Introduction COVID-19 is a pandemic that severely affects the lungs. Symptomatically affected individuals often become severely hypoxic, requiring non-invasive ventilation. The scarcity of resources in resource-compromised countries like India led to the adoption of novel strategies like using Bain's circuit for assisting spontaneous ventilation. This study compares the outcome when a standard circuit is replaced with a shortened Bain's circuit. Aims and objectives To compare shortened Bain's circuit and bilevel positive airway pressure (BiPAP) in spontaneously ventilated COVID 19 patients with regards to effects on hemodynamic stability and efficacy of ventilation using blood gas analysis. Methodology Twenty-four COVID patients aged between 35-70 years, requiring non-invasive ventilation but not tolerating BiPAP or not improving on BiPAP were enrolled in the study. Baseline heart rate and arterial blood gases (ABG) were recorded. Patients were then ventilated using shortened Bain's circuit. Heart rate and ABG were then recorded two hours after ventilation. Results Hemodynamic and blood gas parameters were comparable between the two groups at baseline and on BiPAP. Group A showed better hemodynamic and blood gas profiles compared to group B, but the difference was not statistically significant because of small sample size. Conclusion Shortened Bain's circuit may be a viable alternative to non-invasive ventilation in spontaneously breathing hypoxic patients with efficacy comparable to a standard Bain's circuit and reduced chances of carbon dioxide retention. Studies with a larger sample size are needed to further validate the conclusion.

A retrospective analysis of 902 hospitalized COVID-19 patients in Lebanon: clinical epidemiology and risk factors.

BACKGROUND: The clinical epidemiology of hospitalized COVID-19 patients has never been described before in Lebanon. Moreover, the hospital admission and PCR positivity rates have not been assessed and compared yet. OBJECTIVES: To describe the characteristics and outcomes of hospitalized patients with coronavirus induced disease 2019 (COVID-19) in Lebanon and identify risk factors for severe disease or death. STUDY DESIGN: This is a retrospective mono-center cohort study in which we used patients' files to extract and analyse data on demographic and clinical characteristics, as well as mortality. Moreover, we tracked the pandemic by recording the daily total and ICU inpatient census and the PCR positivity rate for admitted and outpatients. RESULTS: Although the total admission rate increased from September to April, the ICU census switched this trend in December to stabilize at an average of around 10 patients/day until April. The case fatality rate was 19% for the 902 hospitalized patients, of which the majority (80%) had severe COVID-19. The severity odds ratio is significantly decreased in immunosuppressed cases (OR, 0.18; CI, 0.05-0.67; p=0.011). Additionally, the odds of COVID-19 related death are significantly greater if consolidations are found in the chest computed tomography (CT) scan (OR, 12; CI, 2.63-55.08; p=0.0013). CONCLUSION: Consolidations in the lungs significantly increase the COVID-19 death risk. Risk factors identification is important to improve patients' management and vaccination strategies. In addition, hospital statistics are good indicators of a pandemic's track.

High-Flow and High-Pressure Oxygen Mixing for Ventilator System

The treatment of patients with acute respiratory failure due to COVID-19 needs ventilator machine support to provide oxygenation and ventilation processes. The most critical control in the machine is how to provide precision-inspired oxygen fraction (FiO2) to the patients during the treatment. Generally, the low-flow nasal cannula can provide 4-6 liters per minute of supplemental oxygen with approximately 37 - 45% FiO2. In this paper, we present high-flow and high-pressure oxygen mixing to provide up to 100% FiO2 and 60 liters per minute. The proposed system also employs the close-loop feedback control to achieve a desirable FiO2 set point. It can be used for a Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BiPAP) ventilator systems with oxygen as well as a High Flow Nasal Cannula (HFNC) system for acute respiratory patient's syndrome. © 2021 IEEE.

Management of COVID-19-Associated Acute Respiratory Failure with Alternatives to Invasive Mechanical Ventilation: High-Flow Oxygen, Continuous Positive Airway Pressure, and Noninvasive Ventilation.

Patients admitted to hospital with coronavirus disease 2019 (COVID-19) may develop acute respiratory failure (ARF) with compromised gas exchange. These patients require oxygen and possibly ventilatory support, which can be delivered via different devices. Initially, oxygen therapy will often be administered through a conventional binasal oxygen catheter or air-entrainment mask. However, when higher rates of oxygen flow are needed, patients are often stepped up to high-flow nasal cannula oxygen therapy (HFNC), continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), or invasive mechanical ventilation (IMV). BiPAP, CPAP, and HFNC may be beneficial alternatives to IMV for COVID-19-associated ARF. Current evidence suggests that when nasal catheter oxygen therapy is insufficient for adequate oxygenation of patients with COVID-19-associated ARF, CPAP should be provided for prolonged periods. Subsequent escalation to IMV may be implemented if necessary.

Nutrition Therapy in Non-intubated Patients with Acute Respiratory Failure.

PURPOSE OF REVIEW: A challenging aspect of the care for patients with acute respiratory failure is their nutrition management. This manuscript consists of a literature review on nutrition therapy in non-intubated patients with acute respiratory failure receiving high-flow nasal cannula oxygenation or non-invasive positive pressure ventilation. RECENT FINDINGS: Studies show that non-intubated patients with acute respiratory failure either on non-invasive ventilation or high-flow nasal cannula are largely underfed in the initial phase of their hospitalization. Although data is limited, the available evidence suggests the feasibility of initiating oral diet in the majority of these patients in the early phase. Initial evaluation includes mental status evaluation, the Yale swallowing screening protocol, and an assessment of severity of illness. The goal should be to initiate oral diet within 24 h. If patient cannot initiate oral diet, the reason for not initiating oral diet should dictate the next step. For instance, if the reason is failure of the swallow screening, further evaluation with fiberoptic endoscopy is warranted. The inability to provide oral diet for a patient in respiratory distress may a harbinger of failure of non-invasive oxygen therapy and should prompt consideration for endotracheal intubation. We suggest placement of a small-bore feeding tube for enteral nutrition if patient is unable receive oral diet after 48 h. CONCLUSIONS: The nutrition management of these patients is better provided by a multidisciplinary team in a protocolized manner.

Telemanagement of Home-Isolated COVID-19 Patients Using Oxygen Therapy With Noninvasive Positive Pressure Ventilation and Physical Therapy Techniques: Randomized Clinical Trial.

BACKGROUND: With the growing stress on hospitals caused by the COVID-19 pandemic, the need for home-based solutions has become a necessity to support these overwhelmed hospitals. OBJECTIVE: The goal of this study was to compare two nonpharmacological respiratory treatment methods for home-isolated COVID-19 patients using a newly developed telemanagement health care system. METHODS: In this single-blinded randomized clinical trial, 60 patients with stage 1 pneumonia caused by SARS-CoV-2 infection were treated. Group A (n=30) received oxygen therapy with bilevel positive airway pressure (BiPAP) ventilation, and Group B (n=30) received osteopathic manipulative respiratory and physical therapy techniques. Arterial blood gases of PaO2 and PaCO2, pH, vital signs (ie, temperature, respiratory rate, oxygen saturation, heart rate, and blood pressure), and chest computed tomography scans were used for follow-up and for assessment of the course and duration of recovery. RESULTS: Analysis of the results showed a significant difference between the two groups (P<.05), with Group A showing shorter recovery periods than Group B (mean 14.9, SD 1.7 days, and mean 23.9, SD 2.3 days, respectively). Significant differences were also observed between baseline and final readings in all of the outcome measures in both groups (P<.05). Regarding posttreatment satisfaction with our proposed telemanagement health care system, positive responses were given by most of the patients in both groups. CONCLUSIONS: It was found that home-based oxygen therapy with BiPAP can be a more effective prophylactic treatment approach than osteopathic manipulative respiratory and physical therapy techniques, as it can impede exacerbation of early-stage COVID-19 pneumonia. Telemanagement health care systems are promising methods to help in the pandemic-related shortage of hospital beds, as they showed reasonable effectiveness and reliability in the monitoring and management of patients with early-stage COVID-19 pneumonia. TRIAL REGISTRATION: ClinicalTrials.gov NCT04368923; https://clinicaltrials.gov/ct2/show/NCT04368923.

Management of COVID-19 in an adolescent demonstrates lasting effects of extreme prematurity on pulmonary function.

Extremely premature infants have demonstrated increased survival due to advancements in care. This population is at risk for decreased lung function that persists into adolescence. It is important for clinicians to consider this history when treating and assessing such patients who contract SARS-CoV-2 respiratory infection. A 17-year-old, former premature infant of 23 weeks gestation with BPD presented to the pediatric emergency department for evaluation of hypoxia and increased work of breathing in the setting of SARS-CoV-2 infection. He was managed aggressively with early noninvasive respiratory support, Remdesevir, systemic steroids, and convalescent plasma. Utilization of aggressive medical therapies early in the hospital course assisted in preventing intubation and mechanical ventilation for this patient. While there are studies examining the severity of SARS-CoV-2 infection in premature infants, there is a paucity of data on this vulnerable group as they age into adolescence. More studies are needed to assess the severity of illness and optimal management of this population.

Helmet CPAP revisited in COVID-19 pneumonia: A case series.

INTRODUCTION: Noninvasive positive pressure ventilation (NIPPV) plays an important role in the management of respiratory failure. However, since the emergence of the COVID-19 pandemic, utilization of traditional face mask NIPPV has been curtailed in part due to risk of aerosolization of respiratory particles and subsequent health care worker exposure. A randomized clinical trial in 2016 reported that an alternative interface, helmet NIPPV, may be more effective than traditional NIPPV at preventing intubation and improving mortality. The helmet NIPPV interface provides positive airway pressure, while also theoretically minimizing aerosolization, making it a feasible modality in management of respiratory failure in COVID-19 patients. CASE AND OUTCOMES: This report describes a single-center experience of a series of three COVID-19 patients with hypoxemic respiratory failure managed with helmet NIPPV. One patient was able to avoid intubation while a second patient was successfully extubated to NIPPV. Ultimately, the third patient was unable to avoid intubation with helmet NIPPV, although the application of the device was late in the progression of the disease. DISCUSSION: NIPPV is an important modality in the management of respiratory failure and has been shown to reduce the need for immediate endotracheal intubation in select populations. For patients unable to tolerate facemask NIPPV, the helmet provides an alternate interface. In COVID-19 patients, the helmet interface may reduce the risk of virus exposure to health care workers from aerosolization. Based on this experience, we recommend that helmet NIPPV can be considered as a feasible option for the management of patients with COVID-19, whether the goal is to prevent immediate intubation or avoid post-extubation respiratory failure. Randomized studies are needed to definitively validate the use of helmet NIPPV in this population. CONCLUSION: Helmet NIPPV is a feasible therapy to manage COVID-19 patients.

Iatrogenic Pneumothorax and Pneumomediastinum in a Patient with COVID-19.

Co-occurrence of pneumothorax and pneumomediastinum is rare in COVID-19 patients. Positive airway pressure therapy used to improve oxygenation may sometimes worsen clinical outcomes in some patients with severe COVID-19 pneumonia. In this case report, we describe an individual who was diagnosed with COVID-19 and developed bilateral pneumothorax and pneumomediastinum after initiating non-invasive positive airway pressure therapy.

Cerebellar infarction requiring surgical decompression in patient with COVID 19 pathological analysis and brief review.

BACKGROUND: This report and literature review describes a case of a COVID-19 patient who suffered a cerebellar stroke requiring neurosurgical decompression. This is the first reported case of a sub-occipital craniectomy with brain biopsy in a COVID-19 patient showing leptomeningeal venous intimal inflammation. CLINICAL DESCRIPTION: The patient is a 48-year-old SARS-COV-2 positive male with multiple comorbidities, who presented with fevers and respiratory symptoms, and imaging consistent with multifocal pneumonia. On day 5 of admission, the patient had sudden change in mental status, increased C-Reactive Protein, ferritin and elevated Interleukin-6 levels. Head CT showed cerebral infarction from vertebral artery occlusion. Given subsequent rapid neurologic decline from cerebellar swelling and mass effect on his brainstem emergent neurosurgical intervention was performed. Brain biopsy found a vein with small organizing thrombus adjacent to focally proliferative intima with focal intimal neutrophils. CONCLUSION: A young man with COVID-19 and suspected immune dysregulation, complicated by a large cerebrovascular ischemic stroke secondary to vertebral artery thrombosis requiring emergent neurosurgical intervention for decompression with improved neurological outcomes. Brain biopsy was suggestive of inflammation from thrombosed vessel, and neutrophilic infiltration of cerebellar tissue.