The nursing care for the medical device related pressure injury patient with a mucosal pressure injury due to an endotracheal tube: a case report.

BACKGROUND: Pressure injury (PI) due to medical devices is one of the most common PIs, especially in patients treated in intensive care. Medical device-related pressure injuries (MDRPIs), as part of their treatment, require extra care and prevention interventions than injuries caused by immobilization. Standardized nursing models are needed to care for PIs caused by medical devices on mucous membranes. PURPOSE: To provide information about the evaluation and care of the MDRPIs in the mucosal membrane due to the endotracheal tube (ET). CASE REPORT: A 35-year-old male with chronic obstructive pulmonary disease (COPD) and coronavirus disease has MDRPIs on the lower lip edge due to the ET on the fifteenth day after intubation. North American Nursing Diagnosis Association (NANDA) diagnoses were determined by systematically analyzing the data using the Gordon's Functional Health Patterns (GFHP) model in the patient. Nursing care was planned and applied in line with the determined NANDA diagnoses, Nursing Outcomes Classification (NOC) interventions, and using the recommendations of current PI guides for treatment of MDRPIs. CONCLUSION: This case report illustrates MDRPIs resulting from ET and provides information about the formation of MDRPIs and appropriate maintenance therapy. Future research is recommended to examine and evaluate the nursing care and outcome of MDRPIs in different mucosal membranes.

Intubation practices and outcomes for patients with suspected or confirmed COVID-19: a national observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN).

OBJECTIVE: Intubation practices changed during the COVID-19 pandemic to protect healthcare workers from transmission of disease. Our objectives were to describe intubation characteristics and outcomes for patients tested for SARS CoV-2 infection. We compared outcomes between patients testing SARS COV-2 positive with those testing negative. METHODS: We conducted a health records review using the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) registry. We included consecutive eligible patients who presented to one of 47 EDs across Canada between March 1, 2020 and June 20, 2021, were tested for SARS-CoV-2 and intubated in the ED. The primary outcome was the proportion of patients experiencing a post-intubation adverse event during the ED stay. Secondary outcomes included first-pass success, intubation practices, and hospital mortality. We used descriptive statistics to summarize variables with subgroup differences examined using t tests, z tests, or chi-squared tests where appropriate with 95% CIs. RESULTS: Of 1720 patients with suspected COVID-19 who were intubated in the ED during the study period, 337 (19.6%) tested SARS-CoV-2 positive and 1383 (80.4%) SARS-CoV-2 negative. SARS-CoV-2 positive patients presented to hospital with lower oxygen levels than SARS-CoV-2 negative patients (mean pulse oximeter SaO2 86 vs 94%, p < 0.001). In total, 8.5% of patients experienced an adverse event post-intubation. More patients in the SARS-CoV-2 positive subgroup experienced post-intubation hypoxemia (4.5 vs 2.2%, p = 0.019). In-hospital mortality was greater for patients who experienced intubation-related adverse events (43.2 vs 33.2%, p = 0.018). There was no significant difference in adverse event-associated mortality by SARS-CoV-2 status. First-pass success was achieved in 92.4% of all intubations, with no difference by SARS-CoV-2 status. CONCLUSIONS: During the COVID-19 pandemic, we observed a low risk of adverse events associated with intubation, even though hypoxemia was common in patients with confirmed SARS-CoV-2. We observed high rates of first-pass success and low rates of inability to intubate. The limited number of adverse events precluded multivariate adjustments. Study findings should reassure emergency medicine practitioners that system modifications made to intubation processes in response to the COVID-19 pandemic do not appear to be associated with worse outcomes compared to pre-COVID-19 practices.

RéSUMé: OBJECTIF: Les pratiques d'intubation ont changé au cours de la pandémie de COVID-19 afin de protéger le personnel de santé contre la transmission de la maladie. Nos objectifs étaient de décrire les caractéristiques de l'intubation et les résultats pour les patients testés pour l'infection par le CoV-2 du SRAS. Nous avons comparé les résultats entre les patients testés positifs au SARS COV-2 et ceux testés négatifs. MéTHODES: Nous avons effectué un examen des dossiers de santé à l'aide du registre du Réseau canadien d'intervention rapide dans les services d'urgence pour la COVID-19 (RCIRSUC). Nous avons inclus les patients éligibles consécutifs qui se sont présentés à l'un des 47 services d'urgence du Canada entre le 1er mars 2020 et le 20 juin 2021, qui ont été testés pour le SRAS-CoV-2 et qui ont été intubés dans le service d'urgence. Le résultat principal était la proportion de patients ayant subi un événement indésirable après l'intubation pendant leur séjour aux urgences. Les critères de jugement secondaires comprenaient le succès du premier passage, les pratiques d'intubation et la mortalité hospitalière. Nous avons utilisé des statistiques descriptives pour résumer les variables avec des différences de sous-groupes examinées à l'aide de tests t, de tests z ou de tests du chi carré, le cas échéant, avec des IC à 95%. RéSULTATS: Sur les 1720 patients suspects de COVID-19 qui ont été intubés aux urgences pendant la période de l'étude, 337 (19,6%) ont été testés positifs au SARS-CoV-2 et 1383 (80,4%) négatifs au SARS-CoV-2. Les patients positifs au SRAS-CoV-2 se sont présentés à l'hôpital avec des niveaux d'oxygène inférieurs à ceux des patients négatifs pour le SRAS-CoV-2 (oxymètre de pouls moyen SaO2 86% contre 94%, p < 0,001). Au total, 8,5% des patients ont présenté un événement indésirable après l'intubation. Un plus grand nombre de patients du sous-groupe positif au SRAS-CoV-2 ont présenté une hypoxémie post-intubation (4,5% vs 2,2%, p = 0,019). La mortalité hospitalière était plus élevée chez les patients ayant subi des événements indésirables liés à l'intubation (43,2% vs 33,2%, p = 0,018). Il n'y avait pas de différence significative dans la mortalité associée aux événements indésirables selon le statut du SRAS-CoV-2. Le succès du premier passage a été obtenu dans 92,4% de toutes les intubations, sans différence selon le statut SARS-CoV-2 CONCLUSIONS: Pendant la pandémie de COVID-19, nous avons observé un faible risque d'événements indésirables associés à l'intubation, même si l'hypoxémie était fréquente chez les patients atteints de SRAS-CoV-2 confirmé. Nous avons observé des taux élevés de réussite du premier passage et des taux faibles d'incapacité à intuber. Le nombre limité d'événements indésirables a empêché les ajustements multivariés. Les résultats de l'étude devraient rassurer les praticiens de la médecine d'urgence que les modifications apportées aux processus d'intubation en réponse à la pandémie de COVID-19 ne semblent pas être associées à des résultats plus défavorables que les pratiques antérieures à la pandémie de COVID-19.

Response to the first awake prone positioning relates with intubation rate in SARS-CoV-2 patients suffering from acute respiratory failure with moderate to severe hypoxaemia: a retrospective study.

AIMS OF THE STUDY: Awake prone positioning (aPP) in non-intubated patients with severe SARS-CoV-2-related pneumonia improves oxygenation and reduces the intubation rate, but no early predictors for success or failure of the strategy have been described. The main objective of this study was to assess whether response to the first aPP in terms of PaO2/FiO2, alveolar-arterial gradient (Aa-O2), respiratory rate and PaCO2 could predict the need for intubation. As secondary objective, we assessed the effects of aPP on the same parameters for all the sessions considered together. METHODS: Retrospective analysis of consecutive SARS-CoV-2 pneumonia patients suffering from acute respiratory failure with moderate to severe hypoxaemia for whom aPP was performed for at least 45 minutes based on the prescription of the clinician in charge according to predefined criteria. Respiratory rate, blood gases and oxygenation parameters (PaO2/FiO2 and Aa-O2), before and after the first aPP were compared between patients who were subsequently intubated or not. Effects of all the aPP sessions together were also analysed. RESULTS: One hundred and sixty-six patients were admitted for SARS-CoV-2 pneumonia during the study period. Among them, 50 received aPP lasting at least 45 minutes. Because 17 denied consent for data analysis and 2 were excluded because of a "do not intubate order", 31 patients (for a total of 116 aPP sessions without any severe adverse events reported) were included. Among them, 10 (32.3%) were intubated. Mean age ± standard deviation (SD) was 60 ± 12 years. At ICU admission, respiratory rate was 26 ± 7/minute, median PaO2/FiO2 94 (interquartile range [IQR] 74-116) mm Hg and median Aa-O2 412 (IQR 286-427) mm Hg (markedly increased). Baseline characteristics did not statistically differ between patients who subsequently needed intubation or not. During the first aPP, PaO2/FiO2 increased and Aa-O2 decreased. When comparing patients who later where intubated or not, we observed, in the non intubated group only, a clinically significant decrease in median Aa-O2, from 294 (280-414) to 204 (107-281) mm Hg, corresponding to a 40% (26-56%) reduction, and a PaO2/FiO2 increase, from 103 (84-116) to 162 (138-195), corresponding to an increase of 48% (11-93%). The p value is <0.005 for both. When all the aPP sessions (n = 80) were considered together, aPP was associated with a significant increase in PaO2/FiO2 from 112 (80-132) to 156 (86-183) mm Hg (p <0.001) and Aa-O2 decrease from 304 (244-418) to 224 (148-361) mm Hg (p = 0.001). CONCLUSIONS: Awake pronation in spontaneously breathing patients is feasible, and improves PaO2/FiO2 and Aa-O2. Response to the first session seems to be associated with lower intubation rate.

Post-intubation laryngeal injury after COVID-19 treatment causing dyspnea: A report of six cases.

Severe cases of COVID-19 often require orotracheal intubation (OTI) and mechanical ventilation, and post-intubation laryngeal injury (PI-LI) is one of the important complications of OTI. Some studies have claimed that the frequency of PI-LI may be higher in COVID-19 patients as compared with that in non-COVID-19 patients, because of the larger size of endotracheal tube used, the longer OTI time, use of prone positioning of the patients, etc. Herein, we describe six cases of PI-LI who presented with dyspnea after recovering from COVID-19. Five of the patients were male and the median OTI period was 9 days. All the patients showed abnormal endoscopic findings, including posterior glottic synechiae/stenosis or subglottic/posterior glottic granulomas. Four patients required surgical intervention, including tracheostomy, laryngomicrosurgery, or laterofixation of the vocal cord. Many post-COVID-19 patients experience persistent symptoms (post-COVID-19 syndrome), including dyspnea. Two of our patients with dyspnea had been treated by internists as cases of post-COVID-19 syndrome. Therefore, we wish to underscore the need for every healthcare professional to be aware of the possibility of PI-LI after OTI, especially during the ongoing COVID-19 pandemic. Otolaryngologists should undertake endoscopic assessment of the larynx in patients presenting with dyspnea after recovering from COVID-19.

Aerosol Retention Characteristics of Barrier Devices.

BACKGROUND: Disease severity in coronavirus disease 2019 (COVID-19) may be associated with inoculation dose. This has triggered interest in intubation barrier devices to block droplet exposure; however, aerosol protection with these devices is not known. This study hypothesized that barrier devices reduce aerosol outside of the barrier. METHODS: Aerosol containment in closed, semiclosed, semiopen, and open barrier devices was investigated: (1) "glove box" sealed with gloves and caudal drape, (2) "drape tent" with a drape placed over a frame, (3) "slit box" with armholes and caudal end covered by vinyl slit diaphragms, (4) original "aerosol box," (5) collapsible "interlocking box," (6) "simple drape" over the patient, and (7) "no barrier." Containment was investigated by (1) vapor instillation at manikin's right arm with video-assisted visual evaluation and (2) submicrometer ammonium sulfate aerosol particles ejected through the manikin's mouth with ventilation and coughs. Samples were taken from standardized locations inside and around the barriers using a particle counter and a mass spectrometer. Aerosol evacuation from the devices was measured using standard hospital suction, a surgical smoke evacuator, and a Shop-Vac. RESULTS: Vapor experiments demonstrated leakage via arm holes and edges. Only closed and semiclosed devices and the aerosol box reduced aerosol particle counts (median [25th, 75th percentile]) at the operator's mouth compared to no barrier (combined median 29 [-11, 56], n = 5 vs. 157 [151, 166], n = 5). The other barrier devices provided less reduction in particle counts (133 [128, 137], n = 5). Aerosol evacuation to baseline required 15 min with standard suction and the Shop-Vac and 5 min with a smoke evacuator. CONCLUSIONS: Barrier devices may reduce exposure to droplets and aerosol. With meticulous tucking, the glove box and drape tent can retain aerosol during airway management. Devices that are not fully enclosed may direct aerosol toward the laryngoscopist. Aerosol evacuation reduces aerosol content inside fully enclosed devices. Barrier devices must be used in conjunction with body-worn personal protective equipment.

Ulnar Neuropathy After Intermittent Prone Positioning for COVID-19 Infection: A Preliminary Report of 3 Cases.

CASE: We describe a preliminary report of 3 cases of ulnar neuropathy after coronavirus disease 2019 (COVID-19) infection and treatment with intermittent prone positioning. CONCLUSION: Ulnar neuropathy may be associated with recent COVID-19 infection. The natural process of the disease and intermittent prone positioning are likely risk factors contributing to this finding. Conservative management seems to lead to improvement of symptoms.

Use of an innovative cuff pressure control and subglottic secretions drainage system in COVID-19 ARDS patients undergoing pronation.

We conducted a proof of concept study where Anapnoguard endotracheal tubes and its control unit were used in 15 patients with COVID-19 acute respiratory distress syndrome. Anapnoguard system provides suction, venting, rinsing of subglottic space and controls cuff pressure detecting air leakage through the cuff. Alpha-amylase and pepsin levels, as oropharyngeal and gastric microaspiration markers, were assessed from 85 tracheal aspirates in the first 72 h after connection to the system. Oropharyngeal microaspiration occurred in 47 cases (55%). Episodes of gastric microaspiration were not detected. Patient positioning, either prone or supine, did not affect alpha-amylase and pepsin concentration in tracheal secretions. Ventilator-associated pneumonia (VAP) rate was 40%. The use of the AG system provided effective cuff pressure control and subglottic secretions drainage. Despite this, no reduction in the incidence of VAP has been demonstrated, compared to data reported in the current COVID-19 literature. The value of this new technology is worth of being evaluated for the prevention of ventilator-associated respiratory tract infections.

Evaluation of diaphragm thickness to predict intubation requirement and mortality in critical COVID-19 patients.

OBJECTIVES: To investigate the value of measuring the diaphragm thickness (DT) on thorax computed tomography (CT) at intensive care unit (ICU) admission for predicting intubation requirement and mortality among COVID-19 patients. METHODS: This study was carried out in Ankara City Hospital, Ankara, Turkey, from September 2020 to January 2021, with 94 critical COVID-19 patients. The patients' demographic characteristics, laboratory parameters, DT measurements, mechanical ventilation (MV) requirements, and mortality statuses were retrospectively screened. The relationships between DT on initial CT, MV requirement, and mortality were investigated. RESULTS: Diaphragm thickness was lower in patients who required intubation after ICU admission than in non-intubated patients (p=0.006); it was also lower in non-survivors (p=0.009). The threshold values for MV need was 3.35 mm (p=0.004) and 3.275 mm for mortality (p=0.006), according to the receiver operating characteristic analysis used to assess the predictive potential of DT. The non-survivor group had a greater neutrophil-to-lymphocyte ratio (p=0.026). Absolute neutrophil count (p=0.017), neutrophil-to-lymphocyte ratio (p=0.010), and interleukin-6 levels (p=0.027) were higher among patients requiring MV than among non-intubated patients. CONCLUSION: Mortality and MV requirements can be predicted from DT measurements. Diaphragm thickness can facilitate the identification of high-risk patients on CT evaluation at ICU admission.

Should videolaryngoscopy be used first line for all intubations in the post-COVID-19 era?

While previously reserved for use in patients with difficult airways or for trainee education, videolaryngoscopy has come to the forefront of anaesthesia after its use as first line in the intubation of all patients with suspected or confirmed COVID-19. This article examines its suitability for routine first line use in all intubations.

Incidence of and risk factors for postintubation hypotension in critically ill patients with COVID-19. / Incidência e fatores de risco para hipotensão pós-intubação em pacientes críticos com COVID-19.

OBJECTIVE: To evaluate the incidence of risk factors for postintubation hypotension in critically ill patients with COVID-19. METHODS: We conducted a retrospective study of 141 patients with COVID-19 who were intubated in the intensive care unit. Postintubation hypotension was defined as the need for any vasopressor dose at any time within the 60 minutes following intubation. Patients with intubation-related cardiac arrest and hypotension before intubation were excluded from the study. RESULTS: Of the 141 included patients, 53 patients (37.5%) had postintubation hypotension, and 43.6% of the patients (n = 17) were female. The median age of the postintubation hypotension group was 75.0 (interquartile range: 67.0 - 84.0). In the multivariate analysis, shock index ≥ 0.90 (OR = 7.76; 95%CI 3.14 - 19.21; p < 0.001), albumin levels < 2.92g/dL (OR = 3.65; 95%CI 1.49 - 8.96; p = 0.005), and procalcitonin levels (OR = 1.07, 95%CI 1.01 - 1.15; p = 0.045) were independent risk factors for postintubation hypotension. Hospital mortality was similar in patients with postintubation hypotension and patients without postintubation hypotension (92.5% versus 85.2%; p = 0.29). CONCLUSION: The incidence of postintubation hypotension was 37.5% in critically ill COVID-19 patients. A shock index ≥ 0.90 and albumin levels < 2.92g/dL were independently associated with postintubation hypotension. Furthermore, a shock index ≥ 0.90 may be a practical tool to predict the increased risk of postintubation hypotension in bedside scenarios before endotracheal intubation. In this study, postintubation hypotension was not associated with increased hospital mortality in COVID-19 patients.

OBJETIVO: Avaliar a incidência de fatores de risco para hipotensão pósintubação em pacientes críticos com COVID-19. METÓDOS: Foi realizado um estudo retrospectivo com 141 pacientes com COVID-19 que foram intubados na unidade de terapia intensiva. Hipotensão pós-intubação foi definida como a necessidade de qualquer dose de vasopressor a qualquer momento em até 60 minutos após a intubação. Pacientes com parada cardiorrespiratória relacionada à intubação e hipotensão antes da intubação foram excluídos do estudo. RESULTADOS: Dos 141 pacientes incluídos, 53 pacientes (37,5%) e 43,6% dos pacientes (n = 17) eram do sexo feminino. A idade mediana do grupo com hipotensão pós-intubação foi de 75 anos (amplitude interquartil: 67,0 - 84,0). Na análise multivariada, índice de choque ≥ 0,90 (RC = 7,76; IC95% 3,14 - 19,21; p < 0,001), níveis de albumina < 2,92g/dL (RC = 3,65; IC95% 1,49 - 8,96; p = 0,005) e níveis de procalcitonina (RC = 1,07, IC95% 1,01 - 1,15; p = 0,045) foram fatores de risco independentes para hipotensão pós-intubação. A mortalidade hospitalar foi semelhante em pacientes com hipotensão pós-intubação e pacientes sem hipotensão pós-intubação (92,5% versus 85,2%; p = 0,29). CONCLUSÃO: A incidência de hipotensão pós-intubação foi de 37,5% em pacientes críticos com COVID-19. Um índice de choque ≥ 0,90 e níveis de albumina < 2,92g/ dL foram independentemente associados à hipotensão pós-intubação. Além disso, índice de choque ≥ 0,90 pode ser uma ferramenta do leito antes da intubação endotraqueal. Neste estudo, a hipotensão pós-intubação não esteve associada ao aumento da mortalidade hospitalar em pacientes com COVID-19.

Impact of pregnancy on airway complications after intubation for COVID-19 infection: A case series.

Coronavirus disease (COVID-19) is associated with severe acute respiratory illness, often requiring intensive care unit admission. Some patients require prolonged intubation and mechanical ventilation. Post-intubation laryngotracheal stenosis occurs in approximately four to 13 % of adult patients after prolonged intubation in the absence of COVID-19 infection. The rate of COVID-19 related post-intubation laryngotracheal stenosis may be higher. Of 339 pregnant patients with COVID-19, we identified seven who required intubation and mechanical ventilation. Four of the seven developed persistent airway complications, and laryngotracheal stenosis, the most severe, was present in three. Each patient had variations in duration of intubation, endotracheal tube size, re-intubation, presence of superimposed infections, and pre-existing comorbidities. We speculate that underlying physiologic changes of pregnancy in addition to the increased inflammatory state caused by COVID-19 are associated with an increased risk of post-intubation laryngotracheal stenosis. Otolaryngology physicians should have a low threshold for considering this pathophysiology when consulting on obstetric patients who have previously been intubated with COVID-19. Otolaryngologists can educate obstetricians when caring for pregnant patients who have laryngotracheal stenosis, especially those who may require emergency airway management for obstetric indications.

What factors predict craniomandibular disorders in severe COVID-19 survivors after prolonged intubation?

PURPOSES: To estimate and identify predictors of craniomandibular disorders (CMDs) in severe COVID-19 survivors after prolonged intubation ≥ 1 week (SCOVIDS-PI). METHODS: This retrospective study enrolled two cohorts of SCOVIDS-PIs with vs. without CMD during a one-year period. The predictor variables were demographic, dental, anesthetic, and laboratory parameters. The main outcome was presence of CMD until six post-PI months (yes/no). Appropriate statistics were computed with α = 95%. RESULTS: The sample comprised 176 subjects aged 59.2 ± 17.2 years (range, 27-89; 11.9% with CMDs; 30.1% females). CMDs were significantly associated with (1) bilateral posterior tooth loss (P = 0; number needed to screen [NNS] = 1.6), (2) dentofacial skeletal class II/convex face (P = .01; NNS = 2.2), and (3) peak CRP during intensive care ≥ 40 mg/l (P = .01; NNS = 3.5). With combined predictors, NNS became 2 to 4.3. CONCLUSIONS: Three predictors of CMDs in SCOVIDS-PIs: bilateral molar loss, convex face, and CRP ≥ 40 mg/l, indicate CMD screening and/or referral to a CMD specialist, regardless of patients' age, gender, underlying CMDs, or previous dental checkups. Screening ∼2 to 4 "SCOVIDS-PIs with ≥ one predictor" will identify one CMD events/patients during the first six post-PI months.

Lung ultrasound response to awake prone positioning predicts the need for intubation in patients with COVID-19 induced acute hypoxemic respiratory failure: an observational study.

BACKGROUND: Awake prone positioning (APP) reduces the intubation rate in COVID-19 patients treated by high-flow nasal cannula (HFNC). However, the lung aeration response to APP has not been addressed. We aimed to explore the lung aeration response to APP by lung ultrasound (LUS). METHODS: This two-center, prospective, observational study enrolled patients with COVID-19-induced acute hypoxemic respiratory failure treated by HFNC and APP. LUS score was recorded 5-10 min before, 1 h after APP, and 5-10 min after supine in the first APP session within the first three days. The primary outcome was LUS score changes in the first three days. Secondary outcomes included changes in SpO2/FiO2 ratio, respiratory rate and ROX index (SpO2/FiO2/respiratory rate) related to APP, and the rate of treatment success (patients who avoided intubation). RESULTS: Seventy-one patients were enrolled. LUS score decreased from 20 (interquartile range [IQR] 19-24) to 19 (18-21) (p < 0.001) after the first APP session, and to 19 (18-21) (p < 0.001) after three days. Compared to patients with treatment failure (n = 20, 28%), LUS score reduction after the first three days in patients with treatment success (n = 51) was greater (- 2.6 [95% confidence intervals - 3.1 to - 2.0] vs 0 [- 1.2 to 1.2], p = 0.001). A decrease in dorsal LUS score > 1 after the first APP session was associated with decreased risk for intubation (Relative risk 0.25 [0.09-0.69]). APP daily duration was correlated with LUS score reduction in patients with treatment success, especially in dorsal lung zones (r = - 0.76; p < 0.001). CONCLUSIONS: In patients with acute hypoxemic respiratory failure due to COVID-19 and treated by HFNC, APP reduced LUS score. The reduction in dorsal LUS scores after APP was associated with treatment success. The longer duration on APP was correlated with greater lung aeration. Trial registration This study was prospectively registered on clinicaltrials.gov on April 22, 2021. Identification number NCT04855162 .

Intubation Timing in COVID-19 Based on ROX Index and Association With Patient Outcomes.

BACKGROUND: Timing of intubation in COVID-19 is controversial. We sought to determine the association of the ROX (Respiratory rate-OXygenation) index defined as [Formula: see text] divided by [Formula: see text] divided by breathing frequency at the time of intubation with clinical outcomes. METHODS: We conducted a retrospective cohort study of patients with COVID-19 who were intubated by using a database composed of electronic health record data from patients with COVID-19 from 62 institutions. Multivariable logistic regression was used to evaluate the impact of ROX index score on mortality. We analyzed the ROX index as a continuous variable as well as a categorical variable by using cutoffs previously described as predicting success with high-flow nasal cannula. RESULTS: Of 1,087 subjects in the analysis group, the median age was 64 years, and more than half had diabetes; 55.2% died, 1.8% were discharged to hospice, 7.8% were discharged to home, 27.3% were discharged to another institution, and 7.8% had another disposition. Increasing age and a longer time from admission to intubation were associated with mortality. After adjusting for sex, race, age, comorbidities, and days from admission to intubation, an increasing ROX index score at the time of intubation was associated with a lower risk of death. In a logistic regression model, each increase in the ROX index score by 1 at the time of intubation was associated with an 8% reduction in odds of mortality (odds ratio 0.92, 95% CI 0.88-0.95). We also found an odds ratio for death of 0.62 (95% CI 0.47-0.81) for subjects with an ROX index score ≥ 4.88 at the time of intubation. CONCLUSIONS: Among a cohort of subjects with COVID-19 who were ultimately intubated, a higher ROX index at the time of intubation was positively associated with survival.

Post-COVID-19 airway stenosis treated by tracheal resection and anastomosis: a bicentric experience.

Objective: The COVID-19 pandemic was an extraordinary challenge for the global healthcare system not only for the number of patients affected by pulmonary disease, but also for the incidence of long-term sequalae. In this regard, laryngo-tracheal stenosis (LTS) represents one of the most common complications of invasive ventilation. Methods: A case series of patients who underwent tracheal resection and anastomosis (TRA) for post-COVID-19 LTS was collected from June 2020 to September 2021. Results: Among 14 patients included, 50% had diabetes and 64.3% were obese. During intensive care unit stay, mean duration of orotracheal intubation (OTI) was 15.2 days and 10 patients (71.4%) underwent tracheostomy, which was maintained in 7 for an average of 31 days. According to the European Laryngological Society classification, 13 patients (92.9%) had a grade IIIa LTS and one a grade IIIa+. All patients underwent Type A TRA, according to the authors' classification. No major perioperative complications were reported and at the last follow-up all patients were asymptomatic. Conclusions: With the appropriate indications, TRA represents an effective treatment in post-COVID-19 LTS patients. Short OTI times and careful tracheostomy are required in order to reduce the incidence of airway injury.

Association between timing of intubation and clinical outcomes of critically ill patients: A meta-analysis.

PURPOSE: Optimal timing of intubation is controversial. We attempted to investigate the association between timing of intubation and clinical outcomes of critically ill patients. METHODS: PubMed was systematically searched for studies reporting on mortality of critically ill patients undergoing early versus late intubation. Studies involving patients with new coronavirus disease (COVID-19) were excluded because a relevant meta-analysis has been published. "Early" intubation was defined according to the authors of the included studies. All-cause mortality was the primary outcome. Pooled risk ratio (RR) and 95% confidence intervals (CI) were calculated using a random effects model. The meta-analysis was registered with PROSPERO (CRD42021284850). RESULTS: In total, 27 studies involving 15,441 intubated patients (11,943 early, 3498 late) were included. All-cause mortality was lower in patients undergoing early versus late intubation (7338 deaths; 45.8% versus 53.5%; RR 0.92, 95% CI 0.87-0.97; p = 0.001). This was also the case in the sensitivity analysis of studies defining "early" as intubation within 24 h from admission in the intensive care unit (6279 deaths; 45.8% versus 53.6%; RR 0.93, 95% CI 0.89-0.98; p = 0.005). CONCLUSION: Avoiding late intubation may be associated with lower mortality in critically ill patients without COVID-19.