Psychological Factors Influencing Adherence to NIV in Neuromuscular Patients Dependent on Non Invasive Mechanical Ventilation: Preliminary Results.

BACKGROUND: Non-invasive ventilation (NIV) is associated with improvement of both morbility and mortality in patients affected by neuromuscular diseases with chronic respiratory failure. Several studies have also shown that long-term NIV positively impacts the patient's quality of life and perception of disease status. Its effectiveness is likely related to the adherence to NIV. Several factors, patient- and not patient-related, may compromise adherence to NIV, such as physical, behavioral, familiar, and social issues. Few data are currently available on the role of psychological factors in influencing NIV adherence. MATERIALS AND METHODS: In this pilot study, we evaluated the adherence to NIV in a group of 15 adult patients with neuromuscular diseases (Duchenne muscular dystrophy, myotonic dystrophy, and amyotrophic lateral sclerosis) in relation to their grade of depression assessed by the Beck Depression Inventory (BDI) questionnaire. Other data were collected, such as clinical features (age and sex), use of anxiolytic drugs, the presence of a family or professional caregiver, the quality of patient-physician relationship, the beginning of psychological support after BDI screening, and the family acceptance of NIV. NIV adherence was definied as the use of NIV for at least 4 h per night on 70% of nights in a month. RESULTS: The overall rate of NIV adherence was 60%. Based on the BDI questionnaire, patients who were non-adherent to NIV had a higher rate of depression, mainly observed in the oldest patients. The acceptance of NIV by the family and positive physician-patient interaction seem to favor NIV adherence. CONCLUSION: Depression can interfere with NIV adherence in patients with neuromuscolar diseases.

The role of dexmedetomidine in ARDS: an approach to non-intensive care sedation.

Introduction: Severe COVID-19 is a life-threatening condition characterized by complications such as interstitial pneumonia, hypoxic respiratory failure, and acute respiratory distress syndrome (ARDS). Non-pharmacological intervention with mechanical ventilation plays a key role in treating COVID-19-related ARDS but is influenced by a high risk of failure in more severe patients. Dexmedetomidine is a new generation highly selective α2-adrenergic receptor (α2-AR) agonist that provides sedative effects with preservation of respiratory function. The aim of this study is to assess how dexmedetomidine influences gas exchange during non-invasive ventilation (NIV) and high-flow nasal cannula (HFNC) in moderate to severe ARDS caused by COVID-19 in a non-intensive care setting. Methods: This is a single center retrospective cohort study. We included patients who showed moderate to severe respiratory distress. All included subjects had indication to NIV and were suitable for a non-intensive setting of care. A total of 170 patients were included, divided in a control group (n = 71) and a treatment group (DEX group, n = 99). Results: A total of 170 patients were hospitalized for moderate to severe ARDS and COVID-19. The median age was 71 years, 29% females. The median Charlson comorbidity index (CCI) was 2.5. Obesity affected 21% of the study population. The median pO2/FiO2 was 82 mmHg before treatment. After treatment, the increase of pO2/FiO2 ratio was clinically and statistically significant in the DEX group compared to the controls (125 mmHg [97-152] versus 94 mmHg [75-122]; ***p < 0.0001). A significative reduction of NIV duration was observed in DEX group (10 [7-16] days vs. 13 [10-17] days; *p < 0.02). Twenty four patients required IMV in control group (n = 71) and 16 patients in DEX group (n = 99) with a reduction of endotracheal intubation of 62% (OR 0.38; **p < 0.008). A higher incidence of sinus bradycardia was observed in the DEX group. Conclusion: Dexmedetomidine provides a "calm and arousal" status which allows spontaneous ventilation in awake patients treated with NIV and HFNC. The adjunctive therapy with dexmedetomidine is associated with a higher pO2/FiO2, lower duration of NIV, and a lower risk of NIV failure. A higher incidence of sinus bradycardia needs to be considered.

Intermittent abdominal pressure ventilation management in neuromuscular diseases: a Delphi panel Consensus.

BACKGROUND: Intermittent abdominal pressure ventilator (IAPV) use started in the 1930s for ventilatory assistance with muscular dystrophy patients. Later, the device was perfected and expanded for other neuromuscular disorders (NMD). In recent years, the morbidity and mortality tracheotomies and trach tubes related renewed the interest around IAPV. However, there are no guidelines for its use. This study aimed to establish a consensus among physicians involved in its practice to provide IAPV suggestions for the treatment of patients with NMD. METHOD: A 3-step modified Delphi method was used to establish consensus. Fourteen respiratory physicians and one psychiatrist with strong experience in IAPV use and/or who published manuscripts on the topic participated in the panel. A systematic review of the literature was carried out according to the PRISMA to identify existing evidence on IAPV for patients with neuromuscular disorders. RESULTS: In the first round, 34 statements were circulated. Panel members marked 'agree' or 'disagree' for each statement and provided comments. The agreement was reached after the second voting session for all 34 statements. CONCLUSIONS: Panel members agreed and IAPV indications, parameter settings (including procedure protocol), potential limitations, contraindications, complications, monitoring, and follow-up are described. This is the first expert consensus on IAPV.

Long-Term High Flow Nasal Cannula Therapy in Primary and Secondary Bronchiectasis.

BACKGROUND: Bronchiectasis is the consequence of chronic bronchial inflammation, inappropriate mucus clearance, bacterial colonization, and recurrent or chronic infection. High flow therapy (HFT) is a type of non-invasive respiratory therapy, usually delivered through a nasal cannula interface (HFNC). It delivers heated and humidified air with a stable fraction of inspired oxygen and a wide range of possible flow rates. AIM OF THE STUDY: Determine the effectiveness of HFNC as add-on therapy in adult primary and secondary bronchiectasis with frequent acute exacerbations (AEs) and/or hospitalizations. METHODS: This is a single-center crossover study on long-term home therapy with HFNC in adult bronchiectasis. Pharmacological therapy included pulse therapy with mucolytics and bronchodilators. After one year, all patients were switched to additional HFNC. The temperature range was 31-37 °C. The flow range was 35-60 L/m. FiO2 was 0.21. RESULTS: Seventy-eight patients completed the follow-up; 54% were females; the median age was 70 years (IQR 60-76). The etiology of bronchiectasis was mainly post-infective (51%), COPD related (26%), and congenital (11%). AEs at baseline were 2.81 (±2.15). A significant reduction in AEs was observed after 24 months with a mean of 0.45 (±0.66) (f-ratio value 79.703. p-value < 0.00001). No significant difference was observed after HFNC therapy on FEV1 (2.39 ± 0.87 vs. 2.55 ± 0.82; f-ratio 0.79. p-value 0.45) and FVC (2.73 ± 0.88 vs. 2.84 ± 0.90; f-ratio 0.411. p-value 0.66). A significant reduction in mMRC score was observed after HFNC therapy (2.40 ± 0.81 vs. 0.97 ± 0.97 at 2 months vs. 0.60 ± 0.78 at 24 months; f-ratio value 95.512. p-value < 0.00001). CONCLUSIONS: HFNC is a well-tolerated add-on therapy for adult bronchiectasis. Dyspnea improved after 2 months and further after 2 years. The exacerbation rate decreased during the 2 years follow-up. No significant difference was observed in lung function.

A machine learning approach to characterize patients with asthma exacerbation attending an acute care setting.

BACKGROUND: One of the main problems in poorly controlled asthma is the access to the Emergency Department (ED). Using a machine learning (ML) approach, the aim of our study was to identify the main predictors of severe asthma exacerbations requiring hospital admission. METHODS: Consecutive patients with asthma exacerbation were screened for inclusion within 48 hours of ED discharge. A k-means clustering algorithm was implemented to evaluate a potential distinction of different phenotypes. K-Nearest Neighbor (KNN) as instance-based algorithm and Random Forest (RF) as tree-based algorithm were implemented in order to classify patients, based on the presence of at least one additional access to the ED in the previous 12 months. RESULTS: To train our model, we included 260 patients (31.5% males, mean age 47.6 years). Unsupervised ML identified two groups, based on eosinophil count. A total of 86 patients with eosinophiles ≥370 cells/µL were significantly older, had a longer disease duration, more restrictions to daily activities, and lower rate of treatment compared to 174 patients with eosinophiles <370 cells/µL. In addition, they reported lower values of predicted FEV1 (64.8±12.3% vs. 83.9±17.3%) and FEV1/FVC (71.3±9.3 vs. 78.5±6.8), with a higher amount of exacerbations/year. In supervised ML, KNN achieved the best performance in identifying frequent exacerbators (AUROC: 96.7%), confirming the importance of spirometry parameters and eosinophil count, along with the number of prior exacerbations and other clinical and demographic variables. CONCLUSIONS: This study confirms the key prognostic value of eosinophiles in asthma, suggesting the usefulness of ML in defining biological pathways that can help plan personalized pharmacological and rehabilitation strategies.

Evolution of the Clinical Profile and Outcomes of Unvaccinated Patients Affected by Critical COVID-19 Pneumonia from the Pre-Vaccination to the Post-Vaccination Waves in Italy.

The vaccination campaign and the new SARS-CoV-2 variants may have changed the clinical profile and outcomes of patients admitted to sub-intensive unit care. We conducted a retrospective study aimed to compare the clinical and radiological features of unvaccinated critical COVID-19 patients hospitalized during the last pandemic wave (December 2021−February 2022, No-Vax group) and before starting the vaccination campaign (March−December 2020, Pre-Vax group). The No-Vax group was also compared with vaccinated patients of the same pandemic wave (Vax group). With respect to the Pre-Vax group, the No-Vax group contained a higher percentage of smokers (p = 0.0007) and a lower prevalence of males (p = 0.0003). At admission, the No-Vax patients showed both a higher CT score of pneumonia and a worse severe respiratory failure (p < 0.0001). In the No-Vax group, a higher percentage of deaths occurred, though this was not significant. In comparison with the No-Vax group, the Vax patients were older (p = 0.0097), with a higher Charlson comorbidity index (p < 0.0001) and a significantly lower HRCT score (p = 0.0015). The percentage of deaths was not different between the two groups. The No-Vax patients showed a more severe disease in comparison with the Pre-Vax patients, and were younger and had fewer comorbidities than the Vax patients.

Versatility of Intermittent Abdominal Pressure Ventilation in a Case of Complicated Restrictive Respiratory Failure and COVID-19.

BACKGROUND: The intermittent abdominal pressure ventilation (IAPV) is a non-invasive ventilation (NIV) technique that avoids facial interfaces and is a diurnal ventilatory support alternative for neuromuscular patients during stable chronic phases of the disease. Coronavirus disease 2019 (COVID-19) is a novel infection possibly causing acute respiratory distress syndrome (ARDS). Neuromuscular diseases (NMD) and preexisting respiratory failure can be exacerbated by respiratory infection and progress to severe disease and ICU admission with a poor prognosis. AIM: To report on the versatility and feasibility of IAPV in acute restrictive respiratory failure exacerbated by COVID-19. PATIENT: We describe the case of a 33-year-old man with spastic tetraparesis, kyphoscoliosis, and impaired cough, eventually leading to a restrictive ventilation pattern. COVID-19 exacerbated respiratory failure and seizures. An NIV trial failed because of inadequate interface adhesion and intolerance. During NIV, dyspnea and seizures worsened. He underwent a high flow nasal cannula (HFNC) with a fluctuating benefit on gas exchange. IAPV was initiated and although there was a lack of cooperation and inability to sit; the compliance was good and a progressive improvement of gas exchange, respiratory rate, and dyspnea was observed. CONCLUSIONS: IAPV is a versatile type of NIV that can be adopted in complicated restrictive respiratory failure. COVID-19 exacerbates preexisting conditions and is destined to be a disease of frailty. COVID-19 is not a contraindication to IAPV and this kind of ventilation can be employed in selected cases in a specialistic setting. Moreover, this report suggests that IAPV is safe when used in combination with HFNC. This hybrid approach provides the opportunity to benefit from both therapies, and, in this particular case, prevented the intubation with all connected risks.

Negative-Pressure Ventilation in Neuromuscular Diseases in the Acute Setting.

Mechanical ventilation started with negative-pressure ventilation (NPV) during the 1950s to assist patients with respiratory failure, secondary to poliomyelitis. Over the years, technological evolution has allowed for the development of more comfortable devices, leading to an increased interest in NPV. The patients affected by neuromuscular diseases (NMD) with chronic and acute respiratory failure (ARF) may benefit from NPV. The knowledge of the available respiratory-support techniques, indications, contraindications, and adverse effects is necessary to offer the patient a personalized treatment that considers the pathology's complexity.

Aerosol delivery through high-flow nasal therapy: Technical issues and clinical benefits.

High-flow nasal cannula (HFNC) therapy is an oxygen delivery method particularly used in patients affected by hypoxemic respiratory failure. In comparison with the conventional "low flow" oxygen delivery systems, it showed several important clinical benefits. The possibility to nebulize drugs via HFNC represents a desirable medical practice because it allows the administration of inhaled drugs, mostly bronchodilators, without the interruption or modification of the concomitant oxygen therapy. HFNC, by itself has shown to exert a small but significant bronchodilator effect and improves muco-ciliary clearance; thus, the nebulization of bronchodilators through the HFNC circuit may potentially increase their pharmacological activity. Several technical issues have been observed which include the type of the nebulizer that should be used, its position within the HFNC circuit, and the optimal gas flow rates to ensure an efficient drug delivery to the lungs both in "quiet" and "distressed" breathing patterns. The aim of this review has been to summarize the scientific evidence coming from "in vitro" studies and to discuss the results of "in vivo" studies performed in adult subjects, mainly affected by obstructive lung diseases. Most studies seem to indicate the vibrating mesh nebulizer as the most efficient type of nebulizer and suggest to place it preferentially upstream from the humidifier chamber. In a quite breathing patterns, the inhaled dose seems to increase with lower flow rates while in a "distressed" breathing pattern, the aerosol delivery is higher when gas flow was set below the patient's inspiratory flow, with a plateau effect seen when the gas flow reaches approximately 50% of the inspiratory flow. Although several studies have demonstrated that the percentage of the loaded dose nebulized via HFNC reaching the lungs is small, the bronchodilator effect of albuterol seems not to be impaired when compared to the conventional inhaled delivery methods. This is probably attributed to its pharmacological activity. Prospective and well-designed studies in different cohort of patients are needed to standardize and demonstrate the efficacy of the procedure.

Diagnosis and treatment of pneumonia, a common cause of respiratory failure in patients with neuromuscular disorders.

Patients with neuromuscular diseases, during their illness are more susceptible to respiratory infections due to predisposing factors. Ineffective cough and the presence of atelectasis and hypoventilation, dysphagia and drooling can represent risk factors for the development of respiratory infection and fatal respiratory failure. Infections of respiratory tract with acute respiratory failure are the most common reason for hospitalizations, and pneumonia is among the leading causes of morbidity and mortality worldwide. The setting in which pneumonia is acquired heavily influences diagnostic and therapeutic choices. We will focus on aetiopathogenesis, diagnosis and treatment of pneumonia in these subjects, particularly considering the disease severity, rates of antibiotic resistance and the possible complications. In this case consultations with specialized physicians are strongly recommended.

Acute Pancreatitis and COVID-19: A Single-Center Experience.

Gastrointestinal involvement in SARS-CoV-2 disease (COVID-19) can occur and evolve fatally. Reports are emerging that SARS-CoV-2 virus attacks the pancreatic cells, causing the boost of amylase and lipase serum activity and rarely frank pancreatitis. We retrospectively assessed all the patients admitted to the respiratory sub-intensive care and evaluated pancreatitis cases and their course. In our study, we included all patients admitted to our respiratory sub-intensive care unit from 1st to 30th November. All patients had a confirmed diagnosis of COVID-19 and a CT finding of interstitial pneumonia associated with signs of respiratory failure. We observed the course and evaluated who developed acute pancreatitis according to standard definitions. In this study, etiology of acute pancreatitis was defined on the basis of risk factors (ie, biliary pancreatitis was defined in presence of common bile duct stone or sludge at CT or MR). According to the Revised Atlanta Classification, we diagnosed and classified the patients and evaluated the radiological severity according to the Balthazar index and a computed tomography severity index. We found that 19% (15 of 78 patients) met the criteria for acute pancreatitis. The mortality rate among patients with pancreatitis was 20%. Interestingly, in our population, cholelithiasis' imaging findings were found in only 7% of the patients, whereas no patient-reported alcohol consumption. Considering that alcohol and biliary stones represent the two major causes of AP in the general population, it is reasonable to hypothesize that SARS-CoV-2 could play a role in the etiology of acute pancreatitis in a subgroup of these patients.

Remdesivir in Severe COVID-19 and Non-Invasive Ventilation: A Real-Life Experience.

BACKGROUND: Antiviral treatment is a hot topic regarding therapy for COVID-19. Several antiviral drugs have been tested in the months since the pandemic began. Yet only Remdesivir obtained approval after first trials. The best time to administer Remdesivir is still a matter for discussion and this could also depend upon the severity of lung damage and the staging of the infection. METHODS: We performed a real-life study of patients hospitalized forCOVID-19 and receiving non-invasive ventilation (NIV). In this single-center study, a 5 day course of Remdesivir was administered as compassionate use. Further therapeutic supports included antibiotics, low molecular weight heparin and steroids. Data collection included clinical signs and symptoms, gas exchange, laboratory markers of inflammation, and radiological findings. Major outcomes were de-escalation of oxygen-support requirements, clinical improvement defined by weaning from ventilation to oxygen therapy or discharge, and mortality. Adverse drug reactions were also recorded. All data were collected during hospitalization and during a 20-day follow up after treatment. RESULTS: 51 patients were enrolled. A global clinical improvement was recorded in 22 patients (43%) at 12 days, and 36 (71%) at 20 days; in particular, at 12 days, 27 patients (53%) also had a de-escalation of oxygen-support class from a therapeutic point of view. Remdesivir use was associated with a lower hazard ratio for clinical improvement in the elderly (older than 70 years) and in subjects with more extensive lung involvement (total severity score at HRCT of more than 14). The 20-day mortality was 13%. CONCLUSIONS: Results demonstrated that Remdesivir is associated with an improvement in clinical, laboratory and radiological parameters in patients with severe COVID-19 and showed an overall mortality of 13%. We conclude that, in this cohort, Remdesivir was a beneficial add-on therapy for severe COVID-19, especially in adults with moderate lung involvement at HRCT.

Intermittent Abdominal Pressure Ventilation: An Alternative for Respiratory Support.

Intermittent abdominal pressure ventilation is a positive pressure ventilation technique that works with abdominal compressions. It has been known since 1938; however, for many years, it was out of production. In recent years, a new device has been produced that has captured the attention to this old respiratory support technique. We considered eight patients with respiratory failure secondary to a neuromuscular disease (congenital myopathy, Duchenne dystrophy, and amyotrophic lateral sclerosis) intolerant to daytime noninvasive ventilation (NIV). IAPV was proposed as an alternative to NIV. We performed baseline and post-IAPV respiratory function assessment. All patients, two years later, are still using intermittent abdominal ventilation. Intermittent positive abdominal mechanical ventilation can be a valid alternative to noninvasive mechanical ventilation with a nasal or face mask. It improves gas exchange, symptoms, and quality of life, decreases the incidence of pneumonia, and can avert the need for intubation and tracheotomy.

The Role of High Flow Nasal Cannula in COVID-19 Associated Pneumomediastinum and Pneumothorax.

BACKGROUND: Pneumomediastinum, subcutaneous emphysema and pneumothorax are not rarely observed during the COVID-19 pandemic. Such complications can worsen gas exchange and the overall prognosis in critical patients. The aim of this study is to investigate what predisposing factors are related to pneumomediastinum and pneumothorax in SARS-CoV2-Acute Respiratory Distress Syndrome (ARDS), what symptoms may predict a severe and potentially fatal complication and what therapeutical approach may provide a better outcome. METHODS: In this single center cohort study, we recorded data from 45 critically ill COVID-19 patients who developed one or more complicating events among pneumomediastinum, subcutaneous emphysema and pneumothorax. All patients showed ARDS and underwent non-invasive ventilation (NIV) at baseline. Patients with mild to moderate ARDS and pneumomediastinum/pneumothorax (n = 25) received High Flow Nasal Cannula (HFNC), while patients with severe ARDS and pneumomediastinum/pneumothorax underwent HFNC (n = 10) or invasive mechanical ventilation (IMV) (n = 10). RESULTS: Pneumomediastinum/pneumothorax developed in 10.5% of subjects affected by SARS-coV2-ARDS. Dyspnea affected 40% and cough affected 37% of subjects. High resolution computed tomography of the chest showed bilateral diffuse ground glass opacities (GGO) in 100% of subjects. Traction bronchiolectasis, reticulation, crazy paving and distortion were observed in 64%. Furthermore, 36% showed subcutaneous emphysema. Non-severe ARDS cases received HFNC, and 76% patients recovered from pneumomediastinum/pneumothorax over a median follow up of 5 days. Among severe ARDS cases the recovery rate of pneumomediastinum/pneumothorax was 70% with the HFNC approach, and 10% with IMV. CONCLUSION: HFNC is a safe and effective ventilatory approach for critical COVID-19 and has a positive role in associated complications such as pneumomediastinum and pneumothorax.

Daytime alternatives for non-invasive mechanical ventilation in neuromuscular disorders.

Mechanical ventilation in recent years has benefited from the development of new techniques and interfaces. These developments allowed clinicians to offer increasingly personalised therapies with the combination of different complementary techniques for treating respiratory insufficiency in patients with neuromuscular diseases. The mouthpiece ventilation, intermittent abdominal pressure ventilator and the negative pressure ventilation can offer many patients alternative therapy options when ventilation is required for many hours a day. In this non-systematic review, we will highlight the use of alternative methods to non-invasive mechanical ventilation at positive pressure in neuromuscular patients, to ensure the optimal interface for each patient.

Home Management of Patients with Moderate or Severe Respiratory Failure Secondary to COVID-19, Using Remote Monitoring and Oxygen with or without HFNC.

BACKGROUND: Home treatment of patients affected by COVID-19 is still a matter of daily debate. During the clinical evolution of the disease, there are high risks of lung failure, which requires oxygen therapy. Here, we report our clinical experience with at-home treatment using high-flow nasal cannula in non-hospitalised patients with confirmed COVID-19. PATIENTS AND METHODS: In this study, 18 patients with moderate-to-severe respiratory failure secondary to COVID-19 were monitored at home daily for temperature and SpO2 measurements. Other parameters such as saturation of peripheral oxygen (SpO2), SpO2/FiO2 (fraction of inspired oxygen), temperature, and lung performance were monitored periodically. Depending on oxygen requirements, the patients also received either standard oxygen via a face mask or, if higher FiO2 required, high-flow nasal cannula (HFNC). RESULTS: All 18 patients had favourable outcomes and recovered from COVID-19. No death was recorded in this group. CONCLUSION: Our clinical experience proves that high-flow nasal cannula oxygen therapy may be considered for at-home treatment of COVID-19 patients with moderate lung failure. This could be useful for further treatment during the pandemic and may also be considered in future epidemics.

Therapeutic approach for severe COVID-19 and immunocompromised patients. A case series.

BACKGROUND: COVID-19 is a potentially critical infectious disease. Inflammatory response and disease severity may vary according to immune system status. The aim of this case series is to investigate different presentation of COVID-19 in immunocompromised patients. METHODS: this is a single centre case series about 17 immunocompromised patients admitted to our respiratory department during the recent COVID-19 pandemic. White blood cell count, C reactive protein, interleukin 6, lymphocytic subpopulation count (CD4+, CD8+, CD20+) and immunoglobulin count (IgG, IgM, IgA) were measured at hospitalization. RESULTS: the most common causes of immunosuppression observed in our severe COVID-19 population are hematological malignancies, immunosuppressant drugs for transplant, primary immunodeficiency and inflammatory bowel disease. Onset symptoms were fever (88%), cough (53%), dyspnoea (24%), asthenia (35%), anosmia and/or ageusia (17%), expectoration (12%). Compared to benign conditions, patients with malignancies show a lower lymphocytic count (490 vs 1100 cells/uL) and higher interleukin 6 (33 vs 13 pg/mL). CONCLUSIONS: immunocompromised patients are at risk of adverse outcome from COVID-19. Hematological malignancies and anti-CD20 therapies induce a high risk. Primary immunodeficiency and classical immunosuppressant such as calcineurin inhibitors and antimetabolites share an intermediate risk.

Early Prone Positioning and Non-Invasive Ventilation in a Critical COVID-19 Subset. A Single Centre Experience in Southern Italy.

OBJECTIVE: Prone positioning (PP) has demonstrated to be a safe adjunctive therapy for severe acute respiratory distress syndrome (ARDS). There is limited evidence of PP effects on awake patients. This study aimed to investigate the effects and feasibility of PP on coronavirus disease 2019 (COVID-19)-associated awake patients with ARDS in a subintensive setting of care. MATERIAL AND METHODS: This is a single-center case-control study involving patients with severe COVID-19 infection. A total of 29 patients underwent noninvasive ventilation, and PP was initiated 12 h from admission; 18 patients tolerated prone and side positioning for at least 10 h/d and cycled their position every 2 h, and 11 patients had no complaints with PP. RESULTS: A total of 29 patients (25 men and 4 women) with a median age of 64 years showed the average baseline white blood cell count of 8.45×109 cells/L, C-reactive protein of 10.1 mg/L, lactate dehydrogenase of 366 mU/mL, and interleukin-6 of 172 pg/mL. Basal pO2/FiO2 ratio (P/F) was 95 (±56.5) and showed no linear correlation with any of the inflammatory markers tested. Computed tomography findings included ground-glass opacities in 100% (29/29) of patients. Consolidation/atelectasis was found in 58% (17/29) of patients. P/F was homogeneously distributed at baseline in patients with PP (96.5) and without PP (95). P/F during PP increased significantly compared with noncompliant controls (288 vs. 202; p=0.0002). Total duration of respiratory failure was significantly shorter in patients with PP (14 vs. 21 days; p=0.002). The number of days to recover from respiratory failure inversely correlated with PP P/F independently from baseline P/F. CONCLUSION: COVID-19 can lead to a severe impairment of gas exchange regardless of inflammatory status. Therefore, respiratory support may play a major role in COVID-19 treatment. We documented substantial efficacy of PP when started early and for at least 10 h/d. On awake patients, PP feasibility strictly depends on patient's compliance. The interface should be carefully chosen to best fit every patient.

Clinical outcomes of high-flow nasal cannula in COVID-19 associated postextubation respiratory failure. A single-centre case series.

INTRODUCTION: A high-flow nasal cannula (HFNC) is an alternative device for oxygena-tion, which improves gas exchange and reduces the work of breathing. Postextubation respiratory failure causes increased morbidity and mortality. HFNC has been widely employed during the COVID-19 pandemic. The purpose of this paper is to report a single-centre experience on the effectiveness and safety of HFNC in weaning COVID-19 patients. MATERIAL AND METHODS: Nine patients showed severe acute respiratory failure and interstitial pneumonia due to SARS-CoV-2. After mechanical ventilation (5 Helmet CPAP, 4 invasive mechanical ventilation), they were de-escalated to HFNC. Settings were: 34-37°C, flow from 50 to 60 L min-1. FiO2 was set to achieve appropriate SpO2. RESULTS: Nine patients (4 females; age 63 ± 13.27 years; BMI 27.2 ± 4.27) showed a baseline PaO2/FiO2 of 109 ± 45 mm Hg. After a long course of ventilation all patients improved (PaO2/FiO2 336 ± 72 mm Hg). Immediately after initiation of HFNC (2 hours), PaO2/FiO2 was 254 ± 69.3 mm Hg. Mean ROX index at two hours was 11.17 (range: 7.38-14.4). It was consistent with low risk of HFNC failure. No difference was observed on lactate. After 48 hours of HFNC oxygen therapy (day 3), mean PaO2/FiO2 increased to 396 ± 83.5 mm Hg. All patients recovered from respiratory failure after 7 ± 4.1 days. CONCLUSIONS: HFNC might be helpful in weaning COVID-19 respiratory failure. Effectiveness and comfort should be assessed between 2 and 48 hours. Clinical outcomes, oxygenation, and ROX index should be considered, to rule out the need for intubation. Further evidence is required for firm conclusions.

Different presentation of pulmonary parenchymal disruption in COVID-19 pneumonia. Case series of Sub-Intensive Care Unit in Naples, Italy.

The coronavirus disease 2019 (COVID-19) is a recent pandemic that affected more than 5 million people worldwide. Chest high resolution computed tomography (HRCT) is an essential tool in diagnosis and management of the disease. Pulmonary parenchymal opacity is a typical sign of the disease, but not the only one. Pneumothorax, pneumomediastinum, bronchiectasis and cysts are probably underrated complications of COVID-19 that can worsen prognosis, in terms of prolonged hospitalization and need of oxygen therapy. In our single center case series, we outline four different manifestations of pneumothorax, pneumomediastinum and cysts in hospitalized patients with COVID-19 pneumonia.