scholarly journals Low PEEP Mechanical Ventilation and PaO2/FiO2 Ratio Evolution in COVID-19 Patients

2021 ◽  
Author(s):  
Samuele Ceruti ◽  
Marco Roncador ◽  
Andrea Saporito ◽  
Maira Biggiogero ◽  
Andrea Glotta ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Critically Ill ◽  
Distress Syndrome ◽  
Invasive Mechanical Ventilation ◽  
Standard Of Care ◽  
Lung Damage ◽  
Severe Respiratory Distress ◽  
Icu Length Of Stay ◽  
Secondary Endpoints ◽  
Severe Respiratory Distress Syndrome

AbstractInvasive mechanical ventilation (IMV) is the standard treatment in critically ill COVID-19 patients with acute severe respiratory distress syndrome (ARDS). When IMV setting is extremely aggressive, especially through the application of high positive-end-expiratory respiration (PEEP) values, lung damage can occur. Until today, in COVID-19 patients, two types of ARDS were identified (L- and H-type); for the L-type, a lower PEEP strategy was supposed to be preferred, but data are still missing. The aim of this study was to evaluate if a clinical management with lower PEEP values in critically ill L-type COVID-19 patients was safe and efficient in comparison to usual standard of care. A retrospective analysis was conducted on consecutive patients with COVID-19 ARDS admitted to the ICU and treated with IMV. Patients were treated with a lower PEEP strategy adapted to BMI: PEEP 10 cmH2O if BMI < 30 kg m−2, PEEP 12 cmH2O if BMI 30–50 kg m−2, PEEP 15 cmH2O if BMI > 50 kg m−2. Primary endpoint was the PaO2/FiO2 ratio evolution during the first 3 IMV days; secondary endpoints were to analyze ICU length of stay (LOS) and IMV length. From March 2 to January 15, 2021, 79 patients underwent IMV. Average applied PEEP was 11 ± 2.9 cmH2O for BMI < 30 kg m−2 and 16 ± 3.18 cmH2O for BMI > 30 kg m−2. During the first 24 h of IMV, patients’ PaO2/FiO2 ratio presented an improvement (p<0.001; CI 99%) that continued daily up to 72 h (p<0.001; CI 99%). Median ICU LOS was 15 days (10–28); median duration of IMV was 12 days (8–26). The ICU mortality rate was 31.6%. Lower PEEP strategy treatment in L-type COVID-19 ARDS resulted in a PaO2/FiO2 ratio persistent daily improvement during the first 72 h of IMV. A lower PEEP strategy could be beneficial in the first phase of ARDS in critically ill COVID-19 patients.

scholarly journals Extracorporeal membrane oxygenation in the complex therapy for septic shock in a patient with severe lung damage caused by COVID-19

2021 ◽  
pp. 52-57
Author(s):  
E. A. Popov ◽  
V. A. Koriachkin ◽  
I. Yu. Sholin ◽  
A. A. Savenkov ◽  
V. A. Porhanov
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Distress Syndrome ◽  
Lung Damage ◽  
Severe Respiratory Distress ◽  
Early Postpartum Period ◽  
Membrane Oxygenation ◽  
Early Postpartum ◽  
Severe Respiratory Distress Syndrome ◽  
Novel Coronavirus ◽  
Severe Lung

Extracorporeal membrane oxygenation (ECMO) has been used for more than 20 years in the treatment of severe respiratory distress syndrome. However, ECMO in some categories of patients is not sufficiently covered in the literature, due to a small number of registered cases. This group includes pregnant women and women in labor. During the intensive care of such patients, the entire available range of therapeutic manipulations and measures that can favorably affect the outcome of the disease should be used. We have describe a clinical case of successful ECMO in a patient with novel coronavirus disease (COVID-19) and obstetric sepsis developed in the early postpartum period.

scholarly journals Neurological Complications and Noninvasive Multimodal Neuromonitoring in Critically Ill Mechanically Ventilated COVID-19 Patients

2020 ◽  
Vol 11 ◽  
Author(s):  
Denise Battaglini ◽  
Gregorio Santori ◽  
Karthikka Chandraptham ◽  
Francesca Iannuzzi ◽  
Matilde Bastianello ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Length Of Stay ◽  
Critically Ill ◽  
Invasive Mechanical Ventilation ◽  
Optic Nerve Sheath Diameter ◽  
Neurological Complications ◽  
Hemodynamic Changes ◽  
Mechanically Ventilated ◽  
Icu Length Of Stay ◽  
Common Manifestation

Purpose: The incidence and the clinical presentation of neurological manifestations of coronavirus disease-2019 (COVID-19) remain unclear. No data regarding the use of neuromonitoring tools in this group of patients are available.Methods: This is a retrospective study of prospectively collected data. The primary aim was to assess the incidence and the type of neurological complications in critically ill COVID-19 patients and their effect on survival as well as on hospital and intensive care unit (ICU) length of stay. The secondary aim was to describe cerebral hemodynamic changes detected by noninvasive neuromonitoring modalities such as transcranial Doppler, optic nerve sheath diameter (ONSD), and automated pupillometry.Results: Ninety-four patients with COVID-19 admitted to an ICU from February 28 to June 30, 2020, were included in this study. Fifty-three patients underwent noninvasive neuromonitoring. Neurological complications were detected in 50% of patients, with delirium as the most common manifestation. Patients with neurological complications, compared to those without, had longer hospital (36.8 ± 25.1 vs. 19.4 ± 16.9 days, p &lt; 0.001) and ICU (31.5 ± 22.6 vs. 11.5±10.1 days, p &lt; 0.001) stay. The duration of mechanical ventilation was independently associated with the risk of developing neurological complications (odds ratio 1.100, 95% CI 1.046–1.175, p = 0.001). Patients with increased intracranial pressure measured by ONSD (19% of the overall population) had longer ICU stay.Conclusions: Neurological complications are common in critically ill patients with COVID-19 receiving invasive mechanical ventilation and are associated with prolonged ICU length of stay. Multimodal noninvasive neuromonitoring systems are useful tools for the early detection of variations in cerebrovascular parameters in COVID-19.

scholarly journals The Role of Dysbiosis in Critically Ill Patients With COVID-19 and Acute Respiratory Distress Syndrome

2021 ◽  
Vol 8 ◽  
Author(s):  
Denise Battaglini ◽  
Chiara Robba ◽  
Andrea Fedele ◽  
Sebastian Trancǎ ◽  
Samir Giuseppe Sukkar ◽  
...  
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Distress Syndrome ◽  
Body Position ◽  
Clinical Status ◽  
Invasive Mechanical Ventilation ◽  
Severe Respiratory Distress

In late December 2019, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) quickly spread worldwide, and the syndrome it causes, coronavirus disease 2019 (COVID-19), has reached pandemic proportions. Around 30% of patients with COVID-19 experience severe respiratory distress and are admitted to the intensive care unit for comprehensive critical care. Patients with COVID-19 often present an enhanced immune response with a hyperinflammatory state characterized by a “cytokine storm,” which may reflect changes in the microbiota composition. Moreover, the evolution to acute respiratory distress syndrome (ARDS) may increase the severity of COVID-19 and related dysbiosis. During critical illness, the multitude of therapies administered, including antibiotics, sedatives, analgesics, body position, invasive mechanical ventilation, and nutritional support, may enhance the inflammatory response and alter the balance of patients' microbiota. This status of dysbiosis may lead to hyper vulnerability in patients and an inappropriate response to critical circumstances. In this context, the aim of our narrative review is to provide an overview of possible interaction between patients' microbiota dysbiosis and clinical status of severe COVID-19 with ARDS, taking into consideration the characteristic hyperinflammatory state of this condition, respiratory distress, and provide an overview on possible nutritional strategies for critically ill patients with COVID-19-ARDS.

Structured ICU Resource Management in a Pandemic is Associated with Good Outcome in Critically Ill COVID-19 Patients

2020 ◽  
Author(s):  
Sebastian J Klein ◽  
Romuald Bellmann ◽  
Hannes Dejaco ◽  
Stephan Eschertzhuber ◽  
Dietmar Fries ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Intensive Care ◽  
Hospital Mortality ◽  
Critically Ill ◽  
Invasive Mechanical Ventilation ◽  
Simplified Acute Physiology Score ◽  
General Ward ◽  
Icu Length Of Stay ◽  
Icu Discharge ◽  
Median Hospital

Abstract Introduction On February 25th, 2020, the first two patients were tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Tyrol, Austria. Based on alarming reports from the neighboring region Lombardy in Italy, rapid measures were taken to ensure adequate intensive care unit (ICU) preparedness for a surge of critically ill coronavirus disease 2019 (COVID-19) patients.Methods A coordinated county wide step-up approach ensured adequate ICU bed availability for COVID-19 patients avoiding shortage of mechanical ventilation capacity. All patients admitted to an ICU with confirmed or strongly suspected COVID-19 in the region of Tyrol, Austria were recorded in the Tyrolean COVID-19 Intensive Care Registry. Data were censored on July 17th, 2020.Results From March 9th, 2020 to July 17th, 2020, 106 critically ill patients with COVID-19 were admitted to an ICU. Median age was 64 (interquartile range [IQR], 54-74) years and the majority of patients were male (76 patients [71.7%]). Median simplified acute physiology score III (SAPS III) was 56 (IQR, 49-64) points. The median duration from appearance of first symptoms to ICU admission was 8 (IQR, 5-11) days. Frequently observed comorbidities were arterial hypertension in 71 patients (67.0%), cardiovascular (45 patients [42.5%]) and renal comorbidities (21 patients [19.8%]). Invasive mechanical ventilation was required in 72 patients (67.9%), 6 patients (5.6%) required extracorporeal membrane oxygenation treatment. Renal replacement therapy was necessary in 21 patients (19.8%). Median ICU length of stay (LOS) was 18 (IQR, 5-31) days, median hospital LOS was 27 (IQR, 13-49) days.ICU mortality was 21.7% (23 patients), while only one patient (0.9%) died after ICU discharge on a general ward (hospital mortality 22,6%). As of July 17th, 2020, two patients are still hospitalized, one in an ICU, one on a general ward.Conclusions Critically ill COVID-19 patients admitted to an ICU in the region of Tyrol, Austria, showed a high severity of disease often requiring complex treatments with increased lengths of ICU- and hospital stay. Despite that, we found ICU and hospital mortality in this cohort to be remarkably low. Adaptive surge response providing sufficient ICU resources presumably has contributed to the overall favorable outcome.

scholarly journals Neurological Complications and Noninvasive Multimodal Neuromonitoring in Critically ill COVID-19 Patients

2020 ◽  
Author(s):  
Denise Battaglini ◽  
Gregorio Santori ◽  
Karthikka Chandraptham ◽  
Francesca Iannuzzi ◽  
Matilde Bastianello ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Length Of Stay ◽  
Critically Ill ◽  
Invasive Mechanical Ventilation ◽  
Optic Nerve Sheath Diameter ◽  
Neurological Complications ◽  
Hemodynamic Changes ◽  
Icu Length Of Stay ◽  
Registration Number ◽  
Common Manifestation

Abstract Background: The incidence and clinical presentation of neurological manifestations of coronavirus disease 2019 (COVID-19) remain unclear. No data regarding the use of neuromonitoring tools in this group of patients are available. Methods: This is a retrospective study of prospectively collected data. The primary aim was to assess the incidence and type of neurological complications in critically ill COVID-19 patients and their effect on survival, as well as on hospital and intensive care unit (ICU) length-of-stay. The secondary aim was to describe cerebral hemodynamic changes detected by noninvasive neuromonitoring modalities such as transcranial doppler (TCD), optic nerve sheath diameter (ONSD), and pupillometry. Results: Ninety-four patients with COVID-19 receiving mechanical ventilation and admitted to an ICU from February 28 to June 30, 2020, were included in this study. Fifty-three patients underwent noninvasive neuromonitoring. Neurological complications were detected in 47/94 patients (50%), with delirium as the most common manifestation. Patients with neurological complications, compared to those without, had longer hospital (36.8±25.1 vs. 19.4±16.9 days, p <0.001) and ICU (31.5±22.6 vs. 11.5±10.1 days, p <0.001) stay. The duration of mechanical ventilation was independently associated with risk of developing neurological complications (OR 1.100, 95%CI 1.046-1.175, p=0.001). Patients with increased intracranial pressure (ICP) measured by ONSD (19% of the overall population) had longer ICU stays. Conclusions: In conclusion, neurological complications are common in critically ill patients with COVID-19 receiving invasive mechanical ventilation and are associated with prolonged ICU length-of-stay. Multimodal noninvasive neuromonitoring systems are useful tools for early detection of cerebrovascular changes in COVID-19. Registration number: 163/2020

scholarly journals Structured ICU resource management in a pandemic is associated with favorable outcome in critically ill COVID‑19 patients

2020 ◽  
Vol 132 (21-22) ◽  
pp. 653-663
Author(s):  
Sebastian J. Klein ◽  
Romuald Bellmann ◽  
Hannes Dejaco ◽  
Stephan Eschertzhuber ◽  
Dietmar Fries ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Intensive Care ◽  
Critically Ill ◽  
Invasive Mechanical Ventilation ◽  
Simplified Acute Physiology Score ◽  
Icu Mortality ◽  
Icu Length Of Stay ◽  
Significant Difference ◽  
Median Hospital

Summary Introduction On February 25, 2020, the first 2 patients were tested positive for severe acute respiratory syndrome coronavirus‑2 (SARS-CoV-2) in Tyrol, Austria. Rapid measures were taken to ensure adequate intensive care unit (ICU) preparedness for a surge of critically ill coronavirus disease-2019 (COVID-19) patients. Methods This cohort study included all COVID-19 patients admitted to an ICU with confirmed or strongly suspected COVID-19 in the State of Tyrol, Austria. Patients were recorded in the Tyrolean COVID-19 intensive care registry. Date of final follow-up was July 17, 2020. Results A total of 106 critically ill patients with COVID-19 were admitted to 1 of 13 ICUs in Tyrol from March 9 to July 17, 2020. Median age was 64 years (interquartile range, IQR 54–74 years) and the majority of patients were male (76 patients, 71.7%). Median simplified acute physiology score III (SAPS III) was 56 points (IQR 49–64 points). The median duration from appearance of first symptoms to ICU admission was 8 days (IQR 5–11 days). Invasive mechanical ventilation was required in 72 patients (67.9%) and 6 patients (5.6%) required extracorporeal membrane oxygenation treatment. Renal replacement therapy was necessary in 21 patients (19.8%). Median ICU length of stay (LOS) was 18 days (IQR 5–31 days), median hospital LOS was 27 days (IQR 13–49 days). The ICU mortality was 21.7% (23 patients), hospital mortality was 22.6%. There was no significant difference in ICU mortality in patients receiving invasive mechanical ventilation and in those not receiving it (18.1% vs. 29.4%, p = 0.284). As of July 17th, 2020, two patients are still hospitalized, one in an ICU, one on a general ward. Conclusion Critically ill COVID-19 patients in Tyrol showed high severity of disease often requiring complex treatment with increased lengths of ICU and hospital stay. Nevertheless, the mortality was found to be remarkably low, which may be attributed to our adaptive surge response providing sufficient ICU resources.

scholarly journals Superinfections in critically ill COVID-19 patients - an association with Dexamethasone?

2021 ◽  
Author(s):  
Signe Sovik ◽  
Andreas Barrat-Due ◽  
Trine Kasine ◽  
Theresa Olasveengen ◽  
Marianne Wigernes Strand ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Autoimmune Disease ◽  
Multiple Regression ◽  
Critically Ill ◽  
Fungal Infections ◽  
Invasive Mechanical Ventilation ◽  
Standard Of Care ◽  
Patient Characteristics ◽  
Clinical Findings ◽  
Stepwise Multiple Regression

Abstract BacgroundSuper-infections in COVID-19 patients with acute respiratory distress syndrome (ARDS) on mechanical ventilation were initially reported to be rare. Little is known of their incidence after dexamethasone was introduced as standard care. We aimed to determine the incidence and characteristics of superinfections in mechanically ventilated COVID-19 patients during the course of the COVID-19 pandemic, and explore the possible impact of the introduction of dexamethasone as standard therapy. MethodsIn this national, multi-center, observational, retrospective study we included patients ≥ 18 years admitted from March 1 st 2020 to January 31 st 2021 with polymerase chain reaction (PCR)-confirmed SARSCoV-2 infection treated with invasive mechanical ventilation. Data was collected from electronic health records. Patient characteristics, clinical findings, microbiology, length of stay and 90-day survival were examined with backwards stepwise multiple regression. Results155 patients (115 men, mean age 62 years, range 26-84 years) were included. 73 patients (47%) had a total of 101 superinfections where pneumonia dominated (70%). Superinfections were more commonly observed in patients receiving dexamethasone (67% vs 30%, p<0.0001), and in patients with pre-existing autoimmune disease (18% vs 5%, p<0.01). Invasive fungal infections were reported exclusively in dexamethasone-treated patients [9/72 (13%) vs 0/83 (0%), p<0.0001]. There was no difference in 90-day survival between patients with and patients without superinfections (64% versus 73%, p=0.238). In multiple regression analysis, superinfection was associated with dexamethasone use [OR 5.35 (2.62–11.35), p<0.001], pre-existing autoimmune disease [OR 4.90 (1.50–19.4), p=0.008] and higher lymphocyte count at the time of admission [OR 2.31 (1.23–4.86), p=0.009]. ConclusionIn critically ill COVID-19 patients receiving invasive ventilation, introduction of dexamethasone as standard of care was strongly and independently associated with superinfections. A focus on this complication is warranted when studying alternative anti-inflammatory therapy.

scholarly journals Etiology, incidence, and outcomes of patient–ventilator asynchrony in critically-ill patients undergoing invasive mechanical ventilation

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Yongfang Zhou ◽  
Steven R. Holets ◽  
Man Li ◽  
Gustavo A. Cortes-Puentes ◽  
Todd J. Meyer ◽  
...  
Keyword(s):  
Risk Factors ◽  
Mechanical Ventilation ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Invasive Mechanical Ventilation ◽  
Surgical Intensive Care ◽  
Mechanically Ventilated ◽  
History Of ◽  
Training Background ◽  
The Relationship

AbstractPatient–ventilator asynchrony (PVA) is commonly encountered during mechanical ventilation of critically ill patients. Estimates of PVA incidence vary widely. Type, risk factors, and consequences of PVA remain unclear. We aimed to measure the incidence and identify types of PVA, characterize risk factors for development, and explore the relationship between PVA and outcome among critically ill, mechanically ventilated adult patients admitted to medical, surgical, and medical-surgical intensive care units in a large academic institution staffed with varying provider training background. A single center, retrospective cohort study of all adult critically ill patients undergoing invasive mechanical ventilation for ≥ 12 h. A total of 676 patients who underwent 696 episodes of mechanical ventilation were included. Overall PVA occurred in 170 (24%) episodes. Double triggering 92(13%) was most common, followed by flow starvation 73(10%). A history of smoking, and pneumonia, sepsis, or ARDS were risk factors for overall PVA and double triggering (all P < 0.05). Compared with volume targeted ventilation, pressure targeted ventilation decreased the occurrence of events (all P < 0.01). During volume controlled synchronized intermittent mandatory ventilation and pressure targeted ventilation, ventilator settings were associated with the incidence of overall PVA. The number of overall PVA, as well as double triggering and flow starvation specifically, were associated with worse outcomes and fewer hospital-free days (all P < 0.01). Double triggering and flow starvation are the most common PVA among critically ill, mechanically ventilated patients. Overall incidence as well as double triggering and flow starvation PVA specifically, portend worse outcome.

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