Incidence of Barotrauma in Patients With COVID-19 Pneumonia During Prolonged Invasive Mechanical Ventilation – A Case-Control Study

Background: SARS-CoV2 can cause pulmonary failure requiring prolonged invasive mechanical ventilation (MV). Lung protective ventilation strategies are recommended in order to minimize ventilator induced lung injury. Whether patients with COVID-19 have the same risk for complications including barotrauma is still unknown. Therefore, we investigated barotrauma in patients with COVID-19 pneumonia requiring prolonged MV. Methods: All patients meeting diagnosis criteria for ARDS according to the Berlin Definition, with PCR positive SARS-CoV2 infection and prolonged mechanical ventilation, defined as ≥2 days, treated at our ARDS referral center between March and April 2020 were included in a retrospective registry analysis. Complications were detected by manual review of all patient data including respiratory data, imaging studies, and patient files. Results: A total of 20 patients with severe COVID-19 pulmonary failure (Overall characteristics: median age: 61 years, female gender 6, median duration of MV 22 days) were analyzed. Eight patients (40%) developed severe barotrauma during MV (after median 18 days, range: 1-32) including pneumothorax (5/20), pneumomediastinum (5/20), pneumopericard (1/20), and extended subcutaneous emphysema (5/20). Median respirator settings 24 hours before barotrauma were: Peak inspiratory pressure (Ppeak) 29 cm H2O (range: 27-35), positive end-expiratory pressure (PEEP) 14 cm H2O (range: 5-24), tidal volume (VT) 5.4ml/kg predicted body weight (range 0.4-8.6), plateau pressure (Pplateau) 27 cm H2O (range: 19-30). Mechanical ventilation was significantly more invasive on several occasions in patients without barotrauma. Conclusion: Barotrauma in COVID-19 induced respiratory failure requiring mechanical ventilation was found in 40% of patients included in this registry. Our data suggest that barotrauma in COVID-19 may occur even when following recommendations for lung protective MV.

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ARDS: challenges in patient care and frontiers in research

European Respiratory Review ◽

10.1183/16000617.0107-2017 ◽

2018 ◽

Vol 27 (147) ◽

pp. 170107 ◽

Cited By ~ 6

Author(s):

Lieuwe D. Bos ◽

Ignacio Martin-Loeches ◽

Marcus J. Schultz

Keyword(s):

Mechanical Ventilation ◽

Prolonged Mechanical Ventilation ◽

Ventilatory Support ◽

Arterial Oxygen Tension ◽

Biological Marker ◽

Plateau Pressure ◽

Neuromuscular Blocking ◽

Arterial Oxygen ◽

Lung Protective Ventilation ◽

Pharmacological Interventions

This review discusses the clinical challenges associated with ventilatory support and pharmacological interventions in patients with acute respiratory distress syndrome (ARDS). In addition, it discusses current scientific challenges facing researchers when planning and performing trials of ventilatory support or pharmacological interventions in these patients.Noninvasive mechanical ventilation is used in some patients with ARDS. When intubated and mechanically ventilated, ARDS patients should be ventilated with low tidal volumes. A plateau pressure <30 cmH2O is recommended in all patients. It is suggested that a plateau pressure <15 cmH2O should be considered safe. Patient with moderate and severe ARDS should receive higher levels of positive end-expiratory pressure (PEEP). Rescue therapies include prone position and neuromuscular blocking agents. Extracorporeal support for decapneisation and oxygenation should only be considered when lung-protective ventilation is no longer possible, or in cases of refractory hypoxaemia, respectively. Tracheotomy is only recommended when prolonged mechanical ventilation is expected.Of all tested pharmacological interventions for ARDS, only treatment with steroids is considered to have benefit.Proper identification of phenotypes, known to respond differently to specific interventions, is increasingly considered important for clinical trials of interventions for ARDS. Such phenotypes could be defined based on clinical parameters, such as the arterial oxygen tension/inspiratory oxygen fraction ratio, but biological marker profiles could be more promising.

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Temporal changes in the epidemiology, management, and outcome from acute respiratory distress syndrome in European intensive care units: a comparison of two large cohorts

Critical Care ◽

10.1186/s13054-020-03455-8 ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Yasser Sakr ◽

◽

Bruno François ◽

Jordi Solé-Violan ◽

Katarzyna Kotfis ◽

...

Keyword(s):

Mechanical Ventilation ◽

Tidal Volume ◽

Invasive Mechanical Ventilation ◽

Mortality Rates ◽

Plateau Pressure ◽

Temporal Changes ◽

Driving Pressure ◽

Hospital Death ◽

Predicted Body Weight ◽

Risk Of Death

Abstract Background Mortality rates for patients with ARDS remain high. We assessed temporal changes in the epidemiology and management of ARDS patients requiring invasive mechanical ventilation in European ICUs. We also investigated the association between ventilatory settings and outcome in these patients. Methods This was a post hoc analysis of two cohorts of adult ICU patients admitted between May 1–15, 2002 (SOAP study, n = 3147), and May 8–18, 2012 (ICON audit, n = 4601 admitted to ICUs in the same 24 countries as the SOAP study). ARDS was defined retrospectively using the Berlin definitions. Values of tidal volume, PEEP, plateau pressure, and FiO2 corresponding to the most abnormal value of arterial PO2 were recorded prospectively every 24 h. In both studies, patients were followed for outcome until death, hospital discharge or for 60 days. Results The frequency of ARDS requiring mechanical ventilation during the ICU stay was similar in SOAP and ICON (327[10.4%] vs. 494[10.7%], p = 0.793). The diagnosis of ARDS was established at a median of 3 (IQ: 1–7) days after admission in SOAP and 2 (1–6) days in ICON. Within 24 h of diagnosis, ARDS was mild in 244 (29.7%), moderate in 388 (47.3%), and severe in 189 (23.0%) patients. In patients with ARDS, tidal volumes were lower in the later (ICON) than in the earlier (SOAP) cohort. Plateau and driving pressures were also lower in ICON than in SOAP. ICU (134[41.1%] vs 179[36.9%]) and hospital (151[46.2%] vs 212[44.4%]) mortality rates in patients with ARDS were similar in SOAP and ICON. High plateau pressure (> 29 cmH2O) and driving pressure (> 14 cmH2O) on the first day of mechanical ventilation but not tidal volume (> 8 ml/kg predicted body weight [PBW]) were independently associated with a higher risk of in-hospital death. Conclusion The frequency of and outcome from ARDS remained relatively stable between 2002 and 2012. Plateau pressure > 29 cmH2O and driving pressure > 14 cmH2O on the first day of mechanical ventilation but not tidal volume > 8 ml/kg PBW were independently associated with a higher risk of death. These data highlight the continued burden of ARDS and provide hypothesis-generating data for the design of future studies.

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Prediction of prolonged mechanical ventilation for intensive care unit patients: A cohort study

Colombia Medica ◽

10.25100/cm.v44i3.1285 ◽

2013 ◽

pp. 184-188 ◽

Cited By ~ 4

Author(s):

Alvaro Sanabria ◽

Ximena Gomez ◽

Valentin Vega ◽

Luis Carlos Dominguez ◽

Camilo Osorio

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Cohort Study ◽

Intensive Care ◽

Critically Ill ◽

Medical Condition ◽

Prolonged Mechanical Ventilation ◽

Invasive Mechanical Ventilation ◽

Adult Patients ◽

Saps Ii Score

Introduction: There are no established guidelines for selecting patients for early tracheostomy. The aim was to determine the factors that could predict the possibility of intubation longer than 7 days in critically ill adult patients. Methods: This is cohort study made at a general intensive care unit. Patients who required at least 48 hours of mechanical ventilation were included. Data on the clinical and physiologic features were collected for every intubated patient on the third day. Uni- and multivariate statistical analyses were conducted to determine the variables associated with extubation. Results: 163 (62%) were male, and the median age was 59±17 years. Almost one-third (36%) of patients required mechanical ventilation longer than 7 days. The variables strongly associated with prolonged mechanical ventilation were: age (HR 0.97 (95% CI 0.96-0.99); diagnosis of surgical emergency in a patient with a medical condition (HR 3.68 (95% CI 1.62-8.35), diagnosis of surgical condition-non emergency (HR 8.17 (95% CI 2.12-31.3); diagnosis of non-surgical-medical condition (HR 5.26 (95% CI 1.85-14.9); APACHE II (HR 0.91 (95% CI 0.85-0.97) and SAPS II score (HR 1.04 (95% CI 1.00-1.09) The area under ROC curve used for prediction was 0.52. 16% of patients were extubated after day 8 of intubation. Conclusions: It was not possible to predict early extubation in critically ill adult patients with invasive mechanical ventilation with common clinical scales used at the ICU. However, the probability of successfully weaning patients from mechanical ventilation without a tracheostomy is low after the eighth day of intubation.

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Respiratory Failure and Mechanical Ventilation

10.1093/med/9780199918027.003.0006 ◽

2017 ◽

Author(s):

Jan Hau Lee ◽

Ira M. Cheifetz

Keyword(s):

Mechanical Ventilation ◽

Respiratory Failure ◽

Airway Pressure ◽

Positive Airway Pressure ◽

Invasive Mechanical Ventilation ◽

Plateau Pressure ◽

Consensus Definition ◽

Essential Information ◽

Bilevel Positive Airway Pressure ◽

Definition Of

This chapter on respiratory failure and mechanical ventilation provides essential information about how to support children with severe respiratory disorders. The authors discuss multiple modes of respiratory support, including high-flow nasal cannula oxygen, noninvasive ventilation with continuous positive airway pressure and bilevel positive airway pressure, as well as conventional, high-frequency, and alternative modes of invasive ventilation. The section on invasive mechanical ventilation includes key information regarding gas exchange goals, modes of ventilation, patient–ventilator interactions, ventilator parameters (including tidal volume, end-expiratory pressure, and peak plateau pressure), extubation readiness testing, and troubleshooting. The authors also provide the new consensus definition of pediatric acute respiratory distress syndrome. Also included are multiple figures and indispensable information on adjunctive therapies (inhaled nitric oxide, surfactant, prone positioning, and corticosteroids) and respiratory monitoring (including capnography and airway graphics analysis).

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Open Tracheostomy for Critically Ill Patients with COVID-19

International Journal of Otolaryngology ◽

10.1155/2020/8861013 ◽

2020 ◽

Vol 2020 ◽

pp. 1-4

Author(s):

Estefanía Hernández-García ◽

Mar Martínez-RuizCoello ◽

Andrés Navarro Mediano ◽

Nuria Pérez-Martín ◽

Victoria García-Peces ◽

...

Keyword(s):

Mechanical Ventilation ◽

Hospital Admissions ◽

Prolonged Mechanical Ventilation ◽

Invasive Mechanical Ventilation ◽

Epidemiological Data ◽

Orotracheal Intubation ◽

Safe Procedure ◽

Before And After ◽

A Prospective Study ◽

Mean Time

Background. COVID-19 is a worldwide pandemic, with many patients requiring prolonged mechanical ventilation. Tracheostomy can shorten ICU length of stay and help weaning. Aims/Objectives. To describe the long-term evolution of the critically patient with COVID-19 and the need for invasive mechanical ventilation and orotracheal intubation (OTI), with or without tracheostomy. Material and Methods. A prospective study was performed including all patients admitted to the ICU due to COVID-19 from 10th March to 30th April 2020. Epidemiological data, performing a tracheostomy or not, mean time of invasive mechanical ventilation until tracheotomy, mean time from tracheotomy to weaning, and final outcome after one month of minimum follow-up were recorded. The Otolaryngology team was tested for COVID-19 before and after the procedures. Results. Out of a total of 1612 hospital admissions for COVID-19, only 5.8% (93 patients) required ICU admission and IOT. Twenty-seven patients (29%) underwent a tracheostomy. After three months, within the group of tracheotomized patients, 29.6% died and 48.15% were extubated in a mean time of 28.53 days. In the nontracheostomized patients, the mortality was 42.4%. Conclusions. Tracheostomy is a safe procedure for COVID-19 and helps weaning of prolonged OTI. Mortality after tracheostomy was less common than in nontracheostomized patients.

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Post-COVID recovery: characteristics of chronically critically ill patients admitted to a long-term acute care hospital

F1000Research ◽

10.12688/f1000research.26989.2 ◽

2021 ◽

Vol 9 ◽

pp. 1241

Author(s):

Meg Stearn Hassenpflug ◽

Dale Jun ◽

David R. Nelson ◽

Tamas Dolinay

Keyword(s):

Mechanical Ventilation ◽

Acute Care ◽

Prolonged Mechanical Ventilation ◽

Invasive Mechanical Ventilation ◽

Survival Rates ◽

Acute Care Hospital ◽

Infectious Complications ◽

Care Hospital ◽

Chronic Critical Illness

Background: Survivors of COVID-19 pneumonia often suffer from chronic critical illness (CCI) and require long-term hospitalization. Long-term acute care (LTAC) hospitals are vital in the care of CCI patients, but their role for patients post COVID-19 infection is not known. Barlow Respiratory Hospital (BRH) is a 105-bed, LTAC hospital network serving ventilator-dependent and medically-complex patients transferred from the ICUs of hospitals in southern California. We report patient characteristics of our first series of COVID-19 survivors admitted to the post-acute venue of an LTAC hospital. Methods: Single-center observational descriptive report of patients recovering from acute infectious complications of COVID-19 pneumonia requiring long-term respiratory support. Results: From 28 April to 7 September 2020, 41 patients were admitted to BRH for continued recovery from COVID-19 pneumonia. Median age: 68 [44-94] years, 25/41 (61%) male, 33/41 (80.5%) with tracheostomy, 21/41 (51.2%) on invasive mechanical ventilation, 9/41 (22%) receiving hemodialysis. All mechanical ventilation and hemodialysis interventions were initiated at the transferring hospital. Conclusions: To our knowledge, this is the first report to characterize CCI and medically complex COVID-19 patients transferred to the post-acute venue of an LTAC hospital. Patients on average spent over six weeks in the transferring hospital mostly in the ICU, are largely elderly, carry the known risk factors for COVID-19 infection, and experienced respiratory failure necessitating prolonged mechanical ventilation via tracheostomy. Our findings suggest that these patients will continue to require considerable medical interventions and treatments, including weaning from mechanical ventilation, owing to the numerous sequelae of the infection and the burden of acute-on-chronic diseases. As ICU survival rates improve, this research further emphasizes the important role of the LTAC hospital in responding to the COVID-19 crisis.

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ASPECTS OF INVASIVE MECHANICAL VENTILATION IN PATIENTS WITH ARDS CAUSED BY COVID-19

Pain anesthesia and intensive care ◽

10.25284/2519-2078.2(95).2021.238291 ◽

2021 ◽

pp. 9-16

Author(s):

O. A. Loskutov ◽

I. A. Kuchynska ◽

S. M. Nedashkivskyi ◽

O. S. Demchenko

Keyword(s):

Mechanical Ventilation ◽

Multiorgan Failure ◽

Invasive Mechanical Ventilation ◽

Severe Pneumonia ◽

Ideal Body Weight ◽

Plateau Pressure ◽

Invasive Ventilation ◽

Number Of Patients ◽

Number Of Publications ◽

Main Components

Mortality among patients with severe pneumonia and / or acute respiratory distress syndrome (ARDS) due to COVID-19 infection, who underwent mechanical ventilation (MV), is characterized by a fairly high frequency. However, despite the large number of patients receiving appropriate treatment, the question of choosing the optimal ventilation parameters remains poorly understood. In our article, we reviewed the available literature data on the indications for mechanical ventilation, parameters of MV, the need for prone-positioning of patients with ARDS caused by COVID-19 infection in intensive care units to identify unresolved issues.Despite the large number of publications about respiratory support in patients with severe coronavirus infection, there are only general principles regarding the indications for switching to invasive ventilation. Most authors identified the following clinical situations: progression of hypoxemia and / or respiratory failure but with constant oxygen support with increasing percentage of oxygen in the respiratory mixture, use of high-flow cannula or non-invasive ventilation for 1 hour without improvement; persistent hypercapnia, multiorgan failure, coma, high risk of aspiration, hemodynamic instability.According to most of the studies analyzed, the main components of the ventilation strategy should be based on the principles of pulmonary protective ventilation and include the use of low tidal volumes (Vt = 4-8 ml / kg of ideal body weight) and ventilation with plateau pressure Pplat <30 cm H2O (plateau pressure - air pressure measured after an inspiratory pause of 0.5 s). At the same time, many authors recommend using prone position and high levels of positive end-expiratory pressure (PEEP) compared to low levels in patients with ARDS on the background of COVID-19.The approach to invasive mechanical ventilation in ARDS caused by SARS-CoV-2 still requires further research and answers to a number of questions.

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Prolonged Mechanical Ventilation: Challenges to Nurses and Outcome in Extremely Preterm Babies

Critical Care Nurse ◽

10.4037/ccn2015396 ◽

2015 ◽

Vol 35 (4) ◽

pp. 58-66 ◽

Cited By ~ 6

Author(s):

Rachel A. Joseph

Keyword(s):

Mechanical Ventilation ◽

Prolonged Mechanical Ventilation ◽

Invasive Mechanical Ventilation ◽

Technological Advances ◽

Improved Outcomes ◽

Extremely Preterm ◽

Extremely Preterm Infants ◽

Careful Handling ◽

Preterm Babies

Worldwide, about 15 million infants are born prematurely each year. Technological advances, including invasive mechanical ventilation, play a major role in the survival of extremely preterm babies. Those who survive may have prolonged morbid conditions that result in long-term sequelae. Nurses face several challenges during the hospitalization of these infants. Vigilant care, monitoring, and careful handling of the infants can prevent infections and long-term complications. Newer, less invasive technologies are promising for improved outcomes in extremely preterm infants.

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Ventilated Patients With COVID-19 Show Airflow Obstruction

Journal of Intensive Care Medicine ◽

10.1177/08850666211000601 ◽

2021 ◽

pp. 088506662110006

Author(s):

Vikas S. Koppurapu ◽

Maksym Puliaiev ◽

Kevin C. Doerschug ◽

Gregory A. Schmidt

Keyword(s):

Mechanical Ventilation ◽

Respiratory System ◽

Invasive Mechanical Ventilation ◽

Airflow Obstruction ◽

Plateau Pressure ◽

Control Mode ◽

Volume Control ◽

Respiratory System Compliance ◽

University Of Iowa ◽

The University

Objective: Many patients with coronavirus disease 2019 (COVID-19) need mechanical ventilation secondary to acute respiratory distress syndrome. Information on the respiratory system mechanical characteristics of this disease is limited. The aim of this study is to describe the respiratory system mechanical properties of ventilated COVID-19 patients. Design, Setting, and Patients: Patients consecutively admitted to the medical intensive care unit at the University of Iowa Hospitals and Clinics in Iowa City, USA, from April 19 to May 1, 2020, were prospectively studied; final date of follow-up was May 1, 2020. Measurements: At the time of first patient contact, ventilator information was collected including mode, settings, peak airway pressure, plateau pressure, and total positive end expiratory pressure. Indices of airflow resistance and respiratory system compliance were calculated and analyzed. Main Results: The mean age of the patients was 58 years. 6 out of 12 (50%) patients were female. Of the 21 laboratory-confirmed COVID-19 patients on invasive mechanical ventilation, 9 patients who were actively breathing on the ventilator were excluded. All the patients included were on volume-control mode. Mean [±standard deviation] ventilator indices were: resistive pressure 19 [±4] cmH2O, airway resistance 20 [±4] cmH2O/L/s, and respiratory system static compliance 39 [±16] ml/cmH2O. These values are consistent with abnormally elevated resistance to airflow and reduced respiratory system compliance. Analysis of flow waveform graphics revealed a pattern consistent with airflow obstruction in all patients. Conclusions: Severe respiratory failure due to COVID-19 is regularly associated with airflow obstruction.

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Safety and outcomes of percutaneous tracheostomy in coronavirus disease 2019 pneumonitis patients requiring prolonged mechanical ventilation

The Journal of Laryngology & Otology ◽

10.1017/s0022215120002303 ◽

2020 ◽

pp. 1-10

Author(s):

A Takhar ◽

C Tornari ◽

N Amin ◽

D Wyncoll ◽

S Tricklebank ◽

...

Keyword(s):

Mechanical Ventilation ◽

Multidisciplinary Approach ◽

Prolonged Mechanical Ventilation ◽

Percutaneous Tracheostomy ◽

Univariate Analysis ◽

Invasive Mechanical Ventilation ◽

Interquartile Range ◽

Resource Utilisation ◽

Healthcare Resource Utilisation

Abstract Objectives Tracheostomy for coronavirus disease 2019 pneumonitis patients requiring prolonged invasive mechanical ventilation remains a matter of debate. This study analysed the timing and outcomes of percutaneous tracheostomy, and reports our experience of a dedicated ENT–anaesthetics department led tracheostomy team. Method A prospective single-centre observational study was conducted of patients undergoing tracheostomy, who had been diagnosed with coronavirus disease 2019 pneumonitis, between 21st March and 20th May 2020. Results Eighty-one patients underwent tracheostomy after a median (interquartile range) of 16 (13–20) days of invasive mechanical ventilation. Median follow-up duration was 32 (23–40) days. Of patients, 86.7 per cent were successfully liberated from invasive mechanical ventilation in a median (interquartile range) of 12 (7–16) days. Moreover, 68.7 per cent were subsequently discharged from hospital. On univariate analysis, there was no difference in outcomes between early (before day 14) and late (day 14 or later) tracheostomy. The mortality rate was 8.6 per cent and no deaths were tracheostomy related. Conclusion Outcomes appear favourable when patients are carefully selected. Percutaneous tracheostomy performed via a multidisciplinary approach, with appropriate training, was safe and optimised healthcare resource utilisation.

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