scholarly journals Impact of exposure time in awake prone positioning on clinical outcomes of patients with COVID-19-related acute respiratory failure treated with high-flow nasal oxygen: a multicenter cohort study

Critical Care ◽  
2022 ◽  
Vol 26 (1) ◽  
Author(s):  
Mariano Esperatti ◽  
Marina Busico ◽  
Nora Angélica Fuentes ◽  
Adrian Gallardo ◽  
Javier Osatnik ◽  
...  
Keyword(s):  
Cohort Study ◽  
Respiratory Failure ◽  
Hospital Mortality ◽  
Acute Respiratory Failure ◽  
Clinical Outcomes ◽  
Endotracheal Intubation ◽  
High Flow ◽  
Secondary Outcome ◽  
Prone Positioning ◽  
Multicenter Cohort Study

Abstract Background In patients with COVID-19-related acute respiratory failure (ARF), awake prone positioning (AW-PP) reduces the need for intubation in patients treated with high-flow nasal oxygen (HFNO). However, the effects of different exposure times on clinical outcomes remain unclear. We evaluated the effect of AW-PP on the risk of endotracheal intubation and in-hospital mortality in patients with COVID-19-related ARF treated with HFNO and analyzed the effects of different exposure times to AW-PP. Methods This multicenter prospective cohort study in six ICUs of 6 centers in Argentine consecutively included patients > 18 years of age with confirmed COVID-19-related ARF requiring HFNO from June 2020 to January 2021. In the primary analysis, the main exposure was awake prone positioning for at least 6 h/day, compared to non-prone positioning (NON-PP). In the sensitivity analysis, exposure was based on the number of hours receiving AW-PP. Inverse probability weighting–propensity score (IPW-PS) was used to adjust the conditional probability of treatment assignment. The primary outcome was endotracheal intubation (ETI); and the secondary outcome was hospital mortality. Results During the study period, 580 patients were screened and 335 were included; 187 (56%) tolerated AW-PP for [median (p25–75)] 12 (9–16) h/day and 148 (44%) served as controls. The IPW–propensity analysis showed standardized differences < 0.1 in all the variables assessed. After adjusting for other confounders, the OR (95% CI) for ETI in the AW-PP group was 0.36 (0.2–0.7), with a progressive reduction in OR as the exposure to AW-PP increased. The adjusted OR (95% CI) for hospital mortality in the AW-PP group ≥ 6 h/day was 0.47 (0.19–1.31). The exposure to prone positioning ≥ 8 h/d resulted in a further reduction in OR [0.37 (0.17–0.8)]. Conclusion In the study population, AW-PP for ≥ 6 h/day reduced the risk of endotracheal intubation, and exposure ≥ 8 h/d reduced the risk of hospital mortality.

scholarly journals High-flow nasal oxygen in patients with COVID-19-associated acute respiratory failure

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Ricard Mellado-Artigas ◽  
◽  
Bruno L. Ferreyro ◽  
Federico Angriman ◽  
María Hernández-Sanz ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Failure ◽  
Length Of Stay ◽  
Hospital Mortality ◽  
Acute Respiratory Failure ◽  
Invasive Mechanical Ventilation ◽  
High Flow ◽  
Adult Patients ◽  
Icu Length Of Stay ◽  
Early Intubation

Abstract Purpose Whether the use of high-flow nasal oxygen in adult patients with COVID-19 associated acute respiratory failure improves clinically relevant outcomes remains unclear. We thus sought to assess the effect of high-flow nasal oxygen on ventilator-free days, compared to early initiation of invasive mechanical ventilation, on adult patients with COVID-19. Methods We conducted a multicentre cohort study using a prospectively collected database of patients with COVID-19 associated acute respiratory failure admitted to 36 Spanish and Andorran intensive care units (ICUs). Main exposure was the use of high-flow nasal oxygen (conservative group), while early invasive mechanical ventilation (within the first day of ICU admission; early intubation group) served as the comparator. The primary outcome was ventilator-free days at 28 days. ICU length of stay and all-cause in-hospital mortality served as secondary outcomes. We used propensity score matching to adjust for measured confounding. Results Out of 468 eligible patients, a total of 122 matched patients were included in the present analysis (61 for each group). When compared to early intubation, the use of high-flow nasal oxygen was associated with an increase in ventilator-free days (mean difference: 8.0 days; 95% confidence interval (CI): 4.4 to 11.7 days) and a reduction in ICU length of stay (mean difference: − 8.2 days; 95% CI − 12.7 to − 3.6 days). No difference was observed in all-cause in-hospital mortality between groups (odds ratio: 0.64; 95% CI: 0.25 to 1.64). Conclusions The use of high-flow nasal oxygen upon ICU admission in adult patients with COVID-19 related acute hypoxemic respiratory failure may lead to an increase in ventilator-free days and a reduction in ICU length of stay, when compared to early initiation of invasive mechanical ventilation. Future studies should confirm our findings.

scholarly journals High flow nasal oxygen in patients with COVID-19 associated acute respiratory failure

2021 ◽  
Author(s):  
Ricard Mellado Artigas ◽  
Bruno L. Ferreyro ◽  
Federico Angriman ◽  
María Hernández-Sanz ◽  
Egoitz Arruti ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Failure ◽  
Length Of Stay ◽  
Hospital Mortality ◽  
Acute Respiratory Failure ◽  
Invasive Mechanical Ventilation ◽  
High Flow ◽  
Adult Patients ◽  
Icu Length Of Stay ◽  
Early Intubation

Abstract Purpose: Whether the use of high-flow nasal oxygen in adult patients with COVID-19 associated acute respiratory failure improves clinically relevant outcomes remains unclear. We thus sought to assess the effect of high-flow nasal oxygen on ventilator-free days, compared to early initiation of invasive mechanical ventilation, on adult patients with COVID-19.Methods: We conducted a multicentre cohort study using a prospectively collected database of patients with COVID-19 associated acute respiratory failure admitted to 36 Spanish and Andorran intensive care units (ICUs). Main exposure was the use of high-flow nasal oxygen (conservative group), while early invasive mechanical ventilation (within the first day of ICU admission; early intubation group) served as the comparator. The primary outcome was ventilator-free days at 28 days. ICU length of stay and all-cause in-hospital mortality served as secondary outcomes. We used propensity score matching to adjust for measured confounding.Results: Out of 468 eligible patients, a total of 122 matched patients were included in the present analysis (61 for each group). When compared to early intubation, the use of high-flow nasal oxygen was associated with an increase in ventilator-free days (mean difference: 8.0 days; 95% confidence interval (CI): 4.4 to 11.7 days), and a reduction in ICU length of stay (mean difference: -8.2 days; 95% CI -12.7 to -3.6 days). No difference was observed in all-cause in-hospital mortality between groups (odds ratio: 0.64; 95% CI: 0.25 to 1.64).Conclusions: The use of high-flow nasal oxygen upon ICU admission in adult patients with COVID-19 related acute hypoxemic respiratory failure may lead to an increase in ventilator-free days and a reduction in ICU length of stay, when compared to early initiation of invasive mechanical ventilation. Future studies should confirm our findings.

scholarly journals Non-invasive ventilation as the initial ventilatory strategy in very old critically ill patients with community-acquired pneumonia: a multicenter cohort study

2020 ◽  
Author(s):  
Bruno Adler Maccagnan Pinheiro Besen ◽  
Marcelo Park ◽  
Otavio Tavares Ranzani
Keyword(s):  
Mechanical Ventilation ◽  
Cohort Study ◽  
Respiratory Failure ◽  
Hospital Mortality ◽  
Critically Ill ◽  
Community Acquired Pneumonia ◽  
Effect Modification ◽  
Ventilatory Strategy ◽  
Multicenter Cohort Study ◽  
Multicenter Cohort

Abstract Background The very old patients (≥ 80 years-old, VOP) comprise a subpopulation increasingly admitted to intensive care units (ICUs). Community-acquired pneumonia (CAP) is a common reason for admission and the best strategy of mechanical ventilation for respiratory failure in this scenario is not fully known. Methods Multicenter cohort study of VOPs admitted with CAP in need of invasive (IMV) or noninvasive (NIV) mechanical ventilation to 11 Brazilian ICUs from 2009 through 2012. We used logistic regression models to evaluate the association between ventilator strategy (NIV vs. IMV) and hospital mortality adjusting for confounding factors. We evaluated effect modification with interaction terms in pre-specified sub-groups. Results Of 369 VOPs admitted for CAP with respiratory failure, 232 (63%) received NIV and 137 (37%) received IMV as initial ventilatory strategy. IMV patients were sicker at ICU admission (median SOFA 8 vs. 4, p < 0.001). Hospital mortality was 114/232 (49%) for NIV and 90/137 (66%) for IMV. For the comparison NIV vs. IMV (reference), the crude odds ratio (OR) was 0.50 (95% CI, 0.33–0.78, p=0.002). This association was largely confounded by antecedent characteristics and non-respiratory SOFA (adjOR = 0.70, 95% CI, 0.41–1.20, p=0.196). The fully adjusted model, including Pao2/Fio2 ratio, pH and Paco2, yielded an adjOR of 0.81 (95% CI, 0.46–1.41, p=0.452). There was no strong evidence of effect modification among relevant subgroups, such as Pao2/Fio2 ratio ≤ 150 (p = 0.30), acute respiratory acidosis (p = 0.42) and non-respiratory SOFA ≥ 4 (p = 0.53). Conclusions NIV was not associated with lower hospital mortality when compared to IMV in critically ill VOP admitted with CAP, but there was no strong signal of harm from its use. The main confounders of this association were both the severity of respiratory dysfunction and of extra-respiratory organ failures.

scholarly journals Awake Prone Positioning, High-Flow Nasal Oxygen and Non-Invasive Ventilation as Non-Invasive Respiratory Strategies in COVID-19 Acute Respiratory Failure: A Systematic Review and Meta-Analysis

2022 ◽  
Vol 11 (2) ◽  
pp. 391
Author(s):  
Benedikt Schmid ◽  
Mirko Griesel ◽  
Anna-Lena Fischer ◽  
Carolina S. Romero ◽  
Maria-Inti Metzendorf ◽  
...  
Keyword(s):  
Respiratory Failure ◽  
Acute Respiratory Failure ◽  
Standard Care ◽  
Composite Endpoint ◽  
High Flow ◽  
Intubation Rate ◽  
Prone Positioning ◽  
Invasive Ventilation ◽  
Non Invasive ◽  
Non Invasive Ventilation

Background: Acute respiratory failure is the most important organ dysfunction of COVID-19 patients. While non-invasive ventilation (NIV) and high-flow nasal cannula (HFNC) oxygen are frequently used, efficacy and safety remain uncertain. Benefits and harms of awake prone positioning (APP) in COVID-19 patients are unknown. Methods: We searched for randomized controlled trials (RCTs) comparing HFNC vs. NIV and APP vs. standard care. We meta-analyzed data for mortality, intubation rate, and safety. Results: Five RCTs (2182 patients) were identified. While it remains uncertain whether HFNC compared to NIV alters mortality (RR: 0.92, 95% CI 0.65–1.33), HFNC may increase rate of intubation or death (composite endpoint; RR 1.22, 1.03–1.45). We do not know if HFNC alters risk for harm. APP compared to standard care probably decreases intubation rate (RR 0.83, 0.71–0.96) but may have little or no effect on mortality (RR: 1.08, 0.51–2.31). Conclusions: Certainty of evidence is moderate to very low. There is no compelling evidence for either HFNC or NIV, but both carry substantial risk for harm. The use of APP probably has benefits although mortality appears unaffected.

High-Flow Nasal Cannula for Patients with Acute Respiratory Failure Treated in a General Medical Ward: A Prospective Cohort Study

2021 ◽  
Vol 104 (7) ◽  
pp. 1179-1186
Keyword(s):  
Cohort Study ◽  
Respiratory Failure ◽  
Acute Respiratory Failure ◽  
Respiratory Rate ◽  
Prospective Cohort ◽  
High Flow ◽  
Nasal Cannula ◽  
High Flow Nasal Cannula ◽  
General Medical Ward ◽  
Medical Wards

Background: Hypoxemia and the need for oxygen administration are frequent causes of hospital admission. High-flow nasal cannula (HFNC) delivers heated humidified high-flow gas at an adjustable inspired oxygen fraction via a large-bore nasal cannula and provide specific physiological benefits. The efficacy of HFNC has been investigated in the intensive care unit but data in other care settings are scarce, especially in low- and middle-income countries. Objective: To describe the safety and associated clinical outcomes of HFNC used in patients admitted to general medical wards. Materials and Methods: The present study was a prospective cohort study that enrolled adult patients with acute respiratory failure and no other major organ failures admitted to the general medical wards at Siriraj Hospital in Bangkok and treated with HFNC. Enrolled subjects were managed by a multidisciplinary care team trained in HFNC usage. The primary outcome was to determine the rate of HFNC failure, defined as the subsequent need for endotracheal intubation, non-invasive ventilation (NIV), reintubation, or death within 48 hours. Secondary outcomes included determining the in-hospital mortality, 28-day mortality, and the factors associated with HFNC failure. Results: Seventy-one subjects were enrolled. In these patients, acute de novo hypoxemic respiratory failure was the most common indication for HFNC (42.3%), followed by prophylaxis after extubation (38.0%), and cardiogenic pulmonary edema (19.7%). The overall rate of HFNC failure was 25.4%. The overall in-hospital and 28-day mortality rates were 14.1% and 21.1%, respectively. The only factor associated with HFNC failure was the respiratory rate at day 1. Conclusion: The use of HFNC in general medical wards is feasible, but a 25% rate of failure within 48 hours can be expected. A higher respiratory rate at day 1 is associated with the failure of HFNC. Keywords: Acute respiratory failure; General medical ward; High-flow oxygen therapy; Outcomes; Safety

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