Noninvasive Ventilatory Support of Patients with COVID-19 outside the Intensive Care Units (WARd-COVID).

Rationale: Treatment with noninvasive ventilation (NIV) in coronavirus disease (COVID-19) is frequent. Shortage of intensive care unit (ICU) beds led clinicians to deliver NIV also outside ICUs. Data about the use of NIV in COVID-19 is limited.Objectives: To describe the prevalence and clinical characteristics of patients with COVID-19 treated with NIV outside the ICUs. To investigate the factors associated with NIV failure (need for intubation or death).Methods: In this prospective, single-day observational study, we enrolled adult patients with COVID-19 who were treated with NIV outside the ICU from 31 hospitals in Lombardy, Italy.Results: We collected data on demographic and clinical characteristics, ventilatory management, and patient outcomes. Of 8,753 patients with COVID-19 present in the hospitals on the study day, 909 (10%) were receiving NIV outside the ICU. A majority of patients (778/909; 85%) patients were treated with continuous positive airway pressure (CPAP), which was delivered by helmet in 617 (68%) patients. NIV failed in 300 patients (37.6%), whereas 498 (62.4%) patients were discharged alive without intubation. Overall mortality was 25%. NIV failure occurred in 152/284 (53%) patients with an arterial oxygen pressure (PaO2)/fraction of inspired oxygen (FiO2) ratio <150 mm Hg. Higher C-reactive protein and lower PaO2/FiO2 and platelet counts were independently associated with increased risk of NIV failure.Conclusions: The use of NIV outside the ICUs was common in COVID-19, with a predominant use of helmet CPAP, with a rate of success >60% and close to 75% in full-treatment patients. C-reactive protein, PaO2/FiO2, and platelet counts were independently associated with increased risk of NIV failure.Clinical trial registered with ClinicalTrials.gov (NCT04382235).

Lung protective ventilation strategy for the acute respiratory distress syndrome.

BACKGROUND: Patients with acute respiratory distress syndrome and acute lung injury require mechanical ventilatory support. Acute respiratory distress syndrome and acute lung injury are further complicated by ventilator-induced lung injury. Lung protective ventilation strategies may lead to improved survival. This systematic review is an update of a Cochrane review originally published in 2003 and updated in 2007. OBJECTIVES: To assess the effects of ventilation with lower tidal volume on morbidity and mortality in patients aged 16 years or older affected by acute respiratory distress syndrome and acute lung injury. A secondary objective was to determine whether the comparison between low and conventional tidal volume was different if a plateau airway pressure of greater than 30 to 35 cm H20 was used. SEARCH METHODS: In our previous 2007 updated review, we searched databases from inception until 2006. In this third updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL and the Web of Science from 2006 to September 2012. We also updated our search of databases of ongoing research and of reference lists from 2006 to September 2012. SELECTION CRITERIA: We included randomized controlled trials comparing ventilation using either a lower tidal volume (Vt) or low airway driving pressure (plateau pressure 30 cm H2O or less), resulting in a tidal volume of 7 ml/kg or less, versus ventilation that used Vt in the range of 10 to 15 ml/kg in adults (16 years old or older) with acute respiratory distress syndrome and acute lung injury. DATA COLLECTION AND ANALYSIS: We independently assessed trial quality and extracted data. Wherever appropriate, results were pooled. We applied fixed-effect and random-effects models. MAIN RESULTS: We did not find any new study which were eligible for inclusion in this update. The total number of studies remained unchanged, six trials involving 1297 patients. Five trials had a low risk of bias. One trial had an unclear risk of bias. Mortality at day 28 was significantly reduced by lung-protective ventilation with a relative risk (RR) of 0.74 (95% confidence interval (CI) 0.61 to 0.88); hospital mortality was reduced with a RR of 0.80 (95% CI 0.69 to 0.92). Overall mortality was not significantly different if a plateau pressure less than or equal to 31 cm H2O in the control group was used (RR 1.13, 95% CI 0.88 to 1.45). There was insufficient evidence for morbidity and long-term outcomes. AUTHORS' CONCLUSIONS: Clinical heterogeneity, such as different lengths of follow up and higher plateau pressure in control arms in two trials, makes the interpretation of the combined results difficult. Mortality was significantly reduced at day 28 and at the end of the hospital stay. The effects on long-term mortality are unknown, although the possibility of a clinically relevant benefit cannot be excluded. Ventilation with lower tidal volumes is becoming a routine strategy of treatment of acute respiratory distress syndrome and acute lung injury, stopping investigators from carrying out additional trials.

Left ventricle myocardial performance index derived either by conventional method or mitral annulus tissue-Doppler: a comparison study in healthy subjects and subjects with heart failure.

OBJECTIVES: The aims of this study were to investigate the clinical agreement between myocardial performance index (MPI) measured conventionally and by pulsed-wave tissue Doppler (PW-TD) of the mitral annulus, and to test whether PW-TD MPI can accurately differentiate between healthy subjects and patients affected by congestive heart failure (CHF) with mild to moderate reduction of systolic function. BACKGROUND: Calculation of MPI using PW-TD may have advantages over conventional left ventricle inflow/outflow tract pulsed-wave Doppler (PWD) method; for example, all of the data needed for PW-TD MPI calculation can be derived from one single cardiac cycle, whereas with PWD at least two different cycles are needed. Thus, heart rate variability does not interfere with PW-TD MPI. METHODS AND RESULTS: In group A, we included 70 healthy adults with normal left ventricular ejection fraction and normal diastole, whereas for group B we studied 50 patients with CHF and left ventricular ejection fraction between 35% and 45%. MPI measured with PWD was statistically different (P < .0001) from MPI measured with PW-TD both in group A (0.33 +/- 0.09 vs 0.42 +/- 0.09) and group B (0.69 +/- 0.15 vs 0.79 +/- 0.12). Nonetheless, clinical agreement existed between the two methods in the single subject. Receiver operating characteristic curves showed very high accuracy for both methods to discriminate patients with CHF from healthy subjects; the optimal cutoff point was different and specific to each method: 0.50 for the conventional method and 0.60 for the PW-TD method. CONCLUSION: We found clinical agreement between MPI measured in the same subject with the conventional PWD method and with PW-TD. Both methods had similarly high diagnostic accuracy for CHF, but this study supports the use of a higher MPI cut-point for best diagnostic accuracy when using the new PW-TD method. SUMMARY: We performed a study in healthy adults and in patients with congestive heart failure to investigate the clinical agreement between MPI measured conventionally and by PW-TD of the mitral annulus. We found mild agreement between MPI measured by the conventional method and by PW-TD. Both methods had high diagnostic accuracy for CHF. PW-TD method requires a higher MPI cut-point for best diagnostic accuracy.

Ventilation with smaller tidal volumes: a quantitative systematic review of randomized controlled trials.

In this quantitative systematic review we assessed the effects of ventilation with smaller tidal volume (VT) on morbidity and mortality in patients aged 16 yr or older affected by acute lung injury and acute respiratory distress syndrome. Five randomized trials (1202 patients) comparing ventilation using smaller VT and/or low airway driving pressure (plateau pressure 30 cm H2O or less), resulting in VT of 7 mL/kg or less versus ventilation that uses VT in the range of 10 to 15 mL/kg, were identified after a systematic search of The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, databases of current research, reference lists, and "gray literature." Mortality at day 28 was significantly reduced by lung-protective ventilation (relative risk [RR], 0.74; confidence interval [CI], 0.61-0.88), whereas beneficial effect on long-term mortality was uncertain (RR, 0.84; CI, 0.68-1.05). The comparison between small and conventional VT was not significantly different if a plateau pressure less than or equal to 31 cm H2O in the control group was used (RR, 1.13; CI, 0.88-1.45). Clinical heterogeneity, such as different lengths of follow-up and higher plateau pressures in control arms in two trials, make the interpretation of the combined results difficult.

One-minute heart rate recovery after cycloergometer exercise testing as a predictor of mortality in a large cohort of exercise test candidates: substantial differences with the treadmill-derived parameter.

BACKGROUND: Previous work showed a strong inverse association between 1-min heart rate recovery (HRR) after exercising on a treadmill and all-cause mortality. The aim of this study was to determine whether the results could be replicated in a wide population of real-world exercise ECG candidates in our center, using a standard bicycle exercise test. METHODS: Between 1991 and 1997, 1420 consecutive patients underwent ECG exercise testing performed according to our standard cycloergometer protocol. Three pre-specified cut-point values of 1-min HRR, derived from previous studies in the medical literature, were tested to see whether they could identify a higher-risk group for all-cause mortality; furthermore, we tested the possible association between 1-min HRR as a continuous variable and mortality using logistic regression. RESULTS: Both methods showed a lack of a statistically significant association between 1-min HRR and all-cause mortality. A weak trend toward an inverse association, although not statistically significant, could not be excluded. CONCLUSIONS: We could not validate the clear-cut results from some previous studies performed using the treadmill exercise test. The results in our study may only "not exclude" a mild inverse association between 1-min HRR measured after cycloergometer exercise testing and all-cause mortality. The 1-min HRR measured after cycloergometer exercise testing was not clinically useful as a prognostic marker.