scholarly journals Successful awake proning is associated with improved clinical outcomes in patients with COVID-19: single-centre high-dependency unit experience

2020 ◽  
Vol 7 (1) ◽  
pp. e000678 ◽  
Author(s):  
Rob J Hallifax ◽  
Benedict ML Porter ◽  
Patrick JD Elder ◽  
Sarah B Evans ◽  
Chris D Turnbull ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Clinical Outcomes ◽  
High Flow ◽  
Respiratory Support ◽  
Severe Illness ◽  
High Dependency Unit ◽  
Single Centre ◽  
High Dependency ◽  
Improved Outcomes ◽  
Continuous Positive Airways Pressure

The SARS-CoV-2 can lead to severe illness with COVID-19. Outcomes of patients requiring mechanical ventilation are poor. Awake proning in COVID-19 improves oxygenation, but on data clinical outcomes is limited. This single-centre retrospective study aimed to assess whether successful awake proning of patients with COVID-19, requiring respiratory support (continuous positive airways pressure (CPAP) or high-flow nasal oxygen (HFNO)) on a respiratory high-dependency unit (HDU), is associated with improved outcomes. HDU care included awake proning by respiratory physiotherapists. Of 565 patients admitted with COVID-19, 71 (12.6%) were managed on the respiratory HDU, with 48 of these (67.6%) requiring respiratory support. Patients managed with CPAP alone 22/48 (45.8%) were significantly less likely to die than patients who required transfer onto HFNO 26/48 (54.2%): CPAP mortality 36.4%; HFNO mortality 69.2%, (p=0.023); however, multivariate analysis demonstrated that increasing age and the inability to awake prone were the only independent predictors of COVID-19 mortality. The mortality of patients with COVID-19 requiring respiratory support is considerable. Data from our cohort managed on HDU show that CPAP and awake proning are possible in a selected population of COVID-19, and may be useful. Further prospective studies are required.

scholarly journals The role of Continuous Positive Airway Pressure (CPAP) in Delaying or Avoiding Mechanical Ventilation in COVID-19 Respiratory Failure: A Retrospective Cohort Study

2021 ◽  
Author(s):  
Allan Cameron ◽  
Sharif Fattah ◽  
Laura Knox ◽  
Pauline Grose
Keyword(s):  
Mechanical Ventilation ◽  
Cohort Study ◽  
Continuous Positive Airway Pressure ◽  
Airway Pressure ◽  
Positive Airway Pressure ◽  
Invasive Mechanical Ventilation ◽  
Respiratory Support ◽  
Royal Infirmary ◽  
High Dependency ◽  
Number Of Patients

Abstract Background - During the winter of 2020-2021, the second wave of the COVID19 pandemic in the United Kingdom caused increased demand for intensive care unit (ICU) beds, and in particular, for invasive mechanical ventilation (IMV). To alleviate some of this pressure, some centres offered non-invasive continuous positive airway pressure (CPAP), delivered on specialised COVID high dependency units (cHDUs). However, this practice was based largely on anecdotal reports, and it is not clear from the literature how effective CPAP is at delaying or preventing IMV. Methods - This was a retrospective observational cohort study of consecutive patients admitted to a specialised cHDU at Glasgow Royal Infirmary between November 2020 and February 2021. Each patient had a continuous record of the level of respiratory support required, and was followed up to hospital discharge or death. We examined patient outcomes according to age, sex and maximum level of respiratory support, using logistic regression and time-to-event analysis. The number of patients who could not be oxygenated by standard oxygen facemask but could be oxygenated by CPAP was counted and compared to the number of patients admitted to ICU for IMV over the same period.Results - There were 152 admissions to cHDU over the study period. Of these, 125 received CPAP treatment. Of the patients who received support in cHDU, the overall mortality rate was 37.9% (95% CI 30.3% - 46.1%)). Odds of mortality were closely correlated with increasing age and oxygen requirement. Of the 152 patients, 44 patients (28.8%, 95% CI 22.0 – 36.9%) went on to require IMV in ICU. This represents 77.2% of the 57 COVID-19 admissions to ICU during the same period. However, there were also 41 patients who received levels of respiratory support on cHDU which would normally necessitate ICU admission but who never went to ICU, potentially reducing ICU admissions by 41.8% (95% CI 32.1 – 52.2%).Conclusion - Providing respiratory support in cHDU reduced the number of potential ICU admissions by 41.8%, as well as delaying IMV for over 75% of ICU admissions. This represents a significant sparing of ICU capacity at a time when IMV beds were in high demand.

scholarly journals Protocolized Post-Extubation Respiratory Support to prevent reintubation: protocol and statistical analysis plan for a clinical trial

BMJ Open ◽  
2019 ◽  
Vol 9 (8) ◽  
pp. e030476 ◽  
Author(s):  
Jonathan Dale Casey ◽  
Erin R Vaughan ◽  
Bradley D Lloyd ◽  
Peter A Bilas ◽  
Eric J Hall ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Usual Care ◽  
Invasive Mechanical Ventilation ◽  
High Flow ◽  
Respiratory Support ◽  
Invasive Ventilation ◽  
High Flow Nasal Cannula ◽  
Non Invasive ◽  
Non Invasive Ventilation ◽  
Risk Patients

IntroductionFollowing extubation from invasive mechanical ventilation, nearly one in seven critically ill adults requires reintubation. Reintubation is independently associated with increased mortality. Postextubation respiratory support (non-invasive ventilation or high-flow nasal cannula applied at the time of extubation) has been reported in small-to-moderate-sized trials to reduce reintubation rates among hypercapnic patients, high-risk patients without hypercapnia and low-risk patients without hypercapnia. It is unknown whether protocolised provision of postextubation respiratory support to every patient undergoing extubation would reduce the overall reintubation rate, compared with usual care.Methods and analysisThe Protocolized Post-Extubation Respiratory Support (PROPER) trial is a pragmatic, cluster cross-over trial being conducted between 1 October 2017 and 31 March 2019 in the medical intensive care unit of Vanderbilt University Medical Center. PROPER compares usual care versus protocolized post-extubation respiratory support (a respiratory therapist-driven protocol that advises the provision of non-invasive ventilation or high-flow nasal cannula based on patient characteristics). For the duration of the trial, the unit is divided into two clusters. One cluster receives protocolised support and the other receives usual care. Each cluster crosses over between treatment group assignments every 3 months. All adults undergoing extubation from invasive mechanical ventilation are enrolled except those who received less than 12 hours of mechanical ventilation, have ‘Do Not Intubate’ orders, or have been previously reintubated during the hospitalisation. The anticipated enrolment is approximately 630 patients. The primary outcome is reintubation within 96 hours of extubation.Ethics and disseminationThe trial was approved by the Vanderbilt Institutional Review Board. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.Trial registration numberNCT03288311.

scholarly journals Safety and clinical outcomes of remdesivir in hospitalised COVID-19 patients: a retrospective analysis of active surveillance database

2022 ◽  
Vol 22 (1) ◽  
Author(s):  
Vaishali Gupte ◽  
Rashmi Hegde ◽  
Sandesh Sawant ◽  
Kabil Kalathingal ◽  
Sonali Jadhav ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Retrospective Analysis ◽  
Clinical Outcomes ◽  
Oxygen Therapy ◽  
High Flow ◽  
Low Flow ◽  
Invasive Ventilation ◽  
Non Invasive ◽  
Non Invasive Ventilation ◽  
High Flow Oxygen

Abstract Background Real-world data on safety and clinical outcomes of remdesivir in COVID-19 management is scant. We present findings of data analysis conducted for assessing the safety and clinical outcomes of remdesivir treatment for COVID-19 in India. Methods This retrospective analysis used data from an active surveillance programme database of hospitalised patients with COVID-19 who were receiving remdesivir. Results Of the 2329 patients included, 67.40% were men. Diabetes (29.69%) and hypertension (20.33%) were the most common comorbidities. At remdesivir initiation, 2272 (97.55%) patients were receiving oxygen therapy. Remdesivir was administered for 5 days in 65.38% of patients. Antibiotics (64.90%) and steroids (47.90%) were the most common concomitant medications. Remdesivir was overall well tolerated, and total 119 adverse events were reported; most common were nausea and vomiting in 45.40% and increased liver enzymes in 14.28% patients. 84% of patients were cured/improved, 6.77% died and 9.16% showed no improvement in their clinical status at data collection. Subgroup analyses showed that the mortality rate was significantly lower in patients < 60 years old than in those > 60 years old. Amongst patients on oxygen therapy, the cure/improvement rate was significantly higher in those receiving standard low-flow oxygen than in those receiving mechanical ventilation, non-invasive ventilation, or high-flow oxygen. Factors that were associated with higher mortality were age > 60 years, cardiac disease, diabetes high flow oxygen, non-invasive ventilation and mechanical ventilation. Conclusion Our analysis showed that remdesivir is well tolerated and has an acceptable safety profile. The clinical outcome of cure/improvement was 84%, with a higher improvement in patients < 60 years old and on standard low-flow oxygen.

Lost in Transition: Is Early Respiratory Support in Newborn Infants the Best Option?

Neonatology ◽  
2020 ◽  
Vol 117 (4) ◽  
pp. 517-521
Author(s):  
Adam Buckmaster ◽  
Gaston Arnolda ◽  
Louise Owen ◽  
Calum Roberts ◽  
Peter Davis ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Distress ◽  
Treatment Failure ◽  
Newborn Infants ◽  
Supplemental Oxygen ◽  
Late Preterm ◽  
Respiratory Support ◽  
Severe Illness ◽  
Intravenous Fluids ◽  
Using Data

<b><i>Background:</i></b> Late preterm and term newborns with respiratory distress are increasingly treated with non-invasive ventilation (NIV) including nasal high-flow or continuous positive airway pressure. For infants with mild distress, NIV may be unnecessary. <b><i>Objectives:</i></b> We speculated that treatment with supplemental oxygen (SO) prior to NIV could help clinicians select infants for NIV treatment, and examined this hypothesis using data from a recently completed trial. <b><i>Method:</i></b> Post hoc analysis of data from a subset of infants enrolled in the HUNTER trial. Infants born at ≥36 weeks’ gestation were categorized by whether they were receiving SO prior to randomization. The 2 groups were compared for illness severity (indicated by treatment failure at 72 h, mechanical ventilation, need for up-transfer, SO requirement post-randomization, and length of time receiving respiratory support), use of selected medical interventions (antibiotics, intravenous fluids), and breastfeeding at discharge. <b><i>Results:</i></b> Analysis included 380 infants. Infants not receiving SO had less severe illness; lower rates of treatment failure (7.3 vs. 17.2%), mechanical ventilation (0.6 vs. 5.9%), need for transfer (6.8 vs. 13.8%), and more often did not receive any SO post-randomization (75.1 vs. 3.0%). Most infants in both groups received intravenous fluids (93 and 98%) and antibiotics (81 and 93%); the rate of full breastfeeding was low in both groups (51 and 45%). <b><i>Conclusions:</i></b> Late preterm and term newborn infants without SO requirement at the time of commencing NIV for respiratory distress are at lower risk of requiring treatment escalation. Close observation of these infants (watch and wait strategy) may avoid unnecessary treatment.

scholarly journals Predictors of CPAP outcome in hospitalised COVID-19 patients

2020 ◽  
Author(s):  
Y Noeman-Ahmed ◽  
S Gokaraju ◽  
DJ Powrie ◽  
DA Amran ◽  
I El Sayed ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Failure ◽  
Positive Airway Pressure ◽  
Invasive Mechanical Ventilation ◽  
University Hospital ◽  
High Dependency Unit ◽  
Future Studies ◽  
High Dependency ◽  
Management Protocol ◽  
Before And After

AbstractIntroductionThroughout March – April 2020, many patients with COVID-19 presented to Southend University Hospital with Acute Hypoxaemic Respiratory Failure (AHRF). Patients were managed in a Specialist Respiratory High Dependency Unit. We present our experience on the usage of continuous positive airway pressure (CPAP) therapy and possible indicators of its success in this patient group.MethodsData from patients (n=89) requiring mechanical ventilation during the months of March-April 2020, were retrospectively collected and analysed. 37 patients received IMV (Invasive Mechanical Ventilation) without a CPAP trial beforehand. 52 patients underwent a CPAP trial, of which 21 patients successfully avoided intubation and ITU admission.ResultsThe 52 patients, prior to receiving CPAP had significant respiratory failure as evidenced by a low PaO2: FiO2 (PFR) (mean± SD 123 ± 60 mmHg) and mean SpO2:FiO2 (SFR) (mean ± SD: 140 ± 50). The main indicators of CPAP success were: higher SFR before and after CPAP, lower respiratory rate (RR), lower Neutrophil to Lymphocyte ratio (NLR) and higher PFR prior to CPAP.DiscussionCPAP proved successful in 40% of COVID-19 patients presenting with AHRF. SFR, PFR, RR and NLR are predictors of such success. SFR can be used for effective real time monitoring of patients before and after CPAP to identify likelihood of success. Based on our results, we have suggested a modified CPAP management protocol in COVID-19. These findings can guide future studies and will allow improved triage of patients to either CPAP or IMV, in the event of a future COVID peak.

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