scholarly journals The Role of Noninvasive Respiratory Management in Patients with Severe COVID-19 Pneumonia

2021 ◽  
Vol 11 (9) ◽  
pp. 884
Author(s):  
Evangelia Akoumianaki ◽  
Eleni Ischaki ◽  
Konstantinos Karagiannis ◽  
Ioanna Sigala ◽  
Spyros Zakyn-thinos
Keyword(s):  
Respiratory Failure ◽  
Invasive Mechanical Ventilation ◽  
Healthcare Personnel ◽  
Close Monitoring ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure ◽  
Respiratory Management ◽  
Rate Of Success ◽  
Selection Of

Acute hypoxemic respiratory failure is the principal cause of hospitalization, invasive mechanical ventilation and death in severe COVID-19 infection. Nearly half of intubated patients with COVID-19 eventually die. High-Flow Nasal Oxygen (HFNO) and Noninvasive Ventilation (NIV) constitute valuable tools to avert endotracheal intubation in patients with severe COVID-19 pneumonia who do not respond to conventional oxygen treatment. Sparing Intensive Care Unit beds and reducing intubation-related complications may save lives in the pandemic era. The main drawback of HFNO and/or NIV is intubation delay. Cautious selection of patients with severe hypoxemia due to COVID-19 disease, close monitoring and appropriate employment and titration of HFNO and/or NIV can increase the rate of success and eliminate the risk of intubation delay. At the same time, all precautions to protect the healthcare personnel from viral transmission should be taken. In this review, we summarize the evidence supporting the application of HFNO and NIV in severe COVID-19 hypoxemic respiratory failure, analyse the risks associated with their use and provide a path for their proper implementation.

scholarly journals Acute Hypoxemic Respiratory Failure in Children at the Start of COVID-19 Outbreak: A Nationwide Experience

2021 ◽  
Vol 10 (19) ◽  
pp. 4301
Author(s):  
Yolanda M. López-Fernández ◽  
Amelia Martínez-de-Azagra ◽  
José M. González-Gómez ◽  
César Pérez-Caballero Macarrón ◽  
María García-González ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Failure ◽  
Distress Syndrome ◽  
Invasive Mechanical Ventilation ◽  
Oxygenation Index ◽  
Pediatric Intensive Care ◽  
Inclusion Criteria ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure ◽  
Respiratory Management

Study design: This is a prospective, multicenter, and observational study with the aim of describing physiological characteristics, respiratory management, and outcomes of children with acute hypoxemic respiratory failure (AHRF) from different etiologies receiving invasive mechanical ventilation (IMV) compared with those affected by SARS-CoV-2. Methods and Main Results: Twenty-eight patients met the inclusion criteria: 9 patients with coronavirus disease 2019 (COVID-19) and 19 patients without COVID-19. Non-COVID-19 patients had more pre-existing comorbidities (78.9% vs. 44.4%) than COVID-19 patients. At AHRF onset, non-COVID-19 patients had worse oxygenation (PaO2/FiO2 = 95 mmHg (65.5–133) vs. 150 mmHg (105–220), p = 0.04), oxygenation index = 15.9 (11–28.4) vs. 9.3 (6.7–10.6), p = 0.01), and higher PaCO2 (48 mmHg (46.5–63) vs. 41 mmHg (40–45), p = 0.07, that remained higher at 48 h: 54 mmHg (43–58.7) vs. 41 (38.5–45.5), p = 0.03). In 12 patients (5 COVID-19 and 7 non-COVID-19), AHRF evolved to pediatric acute respiratory distress syndrome (PARDS). All non-COVID-19 patients had severe PARDS, while 3 out of 5 patients in the COVID-19 group had mild or moderate PARDS. Overall Pediatric Intensive Care Medicine (PICU) mortality was 14.3%. Conclusions: Children with AHRF due to SARS-CoV2 infection had fewer comorbidities and better oxygenation than patients with non-COVID-19 AHRF. In this study, progression to severe PARDS was rarely observed in children with COVID-19.

scholarly journals Effect of early versus delayed or no intubation on clinical outcomes of patients with COVID-19 

2020 ◽  
Author(s):  
Ilias Siempos ◽  
Elena Xourgia ◽  
Theodora K. Ntaidou ◽  
Dimitris Zervakis ◽  
Eleni E. Magira ◽  
...  
Keyword(s):  
Respiratory Failure ◽  
Clinical Outcomes ◽  
Controlled Trial ◽  
Invasive Mechanical Ventilation ◽  
Optimal Timing ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure ◽  
Entire Cohort ◽  
Early Intubation ◽  
General Wards

Abstract Background: Optimal timing of initiation of invasive mechanical ventilation in patients with acute hypoxemic respiratory failure due to COVID-19 is unknown. Thanks to early flattening of the epidemiological curve, ventilator demand in Greece was kept lower than supply throughout the pandemic, allowing for unbiased comparison of the outcomes of patients undergoing early intubation versus delayed or no intubation.Methods: We conducted an observational study including all adult patients with laboratory-confirmed COVID-19 consecutively admitted in Evangelismos Hospital, Athens, Greece between March 11, 2020 and April 15, 2020. Patients subsequently admitted in the intensive care unit (ICU) were categorized into the “early intubation” versus the “delayed or no intubation” group.Results: During the study period, a total of 101 patients (37% female, median age 65 years) were admitted in the hospital. Fifty-nine patients (58% of the entire cohort) were exclusively hospitalized in general wards with a mortality of 3% and median length of stay of 7 days. Forty-two patients (19% female, median age 65 years, 62% with at least one comorbidity, 14% never intubated) were admitted in the ICU; all with acute hypoxemic respiratory failure. Early intubation was not associated with higher ICU-mortality (21% versus 33%), fewer ventilator-free days (3 versus 2 days) or fewer ICU-free days than delayed or no intubation.Conclusions: A strategy of early intubation was not associated with worse clinical outcomes compared to delayed or no intubation. Given that early intubation may presumably reduce virus aerosolization, these results may justify further research with a randomized controlled trial.

scholarly journals Non-Invasive Oxygenation Strategies in Adult Patients with Acute Respiratory Failure: A Protocol for a Systematic Review and Network Meta-analysis

2020 ◽  
Author(s):  
Bruno Leonel Ferreyro ◽  
Federico Angriman ◽  
Laveena Munshi ◽  
Lorenzo del Sorbo ◽  
Niall D Ferguson ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Failure ◽  
Acute Respiratory Failure ◽  
Meta Analysis ◽  
Invasive Mechanical Ventilation ◽  
Risk Of Bias ◽  
Adult Patients ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure ◽  
Non Invasive

Abstract Background: Acute hypoxemic respiratory failure is one of the leading causes of intensive care unit admission and associated with high mortality. Non-invasive oxygenation strategies such as high flow nasal cannula, standard oxygen therapy and non-invasive ventilation (delivered by either face mask or helmet interface) are widely available interventions applied in these patients. It remains unclear which of these interventions are more effective in decreasing rates of invasive mechanical ventilation and mortality. The primary objective of this network meta-analysis is to summarize the evidence and compare the effect of non-invasive oxygenation strategies on mortality and need for invasive mechanical ventilation in patients with acute hypoxemic respiratory failure. Methods: We will search key databases for randomized controlled trials assessing the effect of non-invasive oxygenation strategies in adult patients with acute hypoxemic respiratory failure. We will exclude studies in which the primary focus is either acute exacerbations of chronic obstructive pulmonary disease or cardiogenic pulmonary edema. The primary outcome will be all-cause mortality (longest available up to 90 days). The secondary outcomes will be receipt of invasive mechanical ventilation (longest available up to 30 days). We will assess the risk of bias for each of the outcomes using the Cochrane Risk of Bias Tool. Bayesian network meta-analyses will be conducted to obtain pooled estimates of head-to-head comparisons. We will report pairwise and network meta-analysis treatment effect estimates as risk ratios and 95% credible intervals. Subgroup analyses will be conducted examining key populations including immunocompromised hosts. Sensitivity analyses will be conducted by excluding those studies with high risk of bias and different etiologies of acute respiratory failure. We will assess certainty in effect estimates using GRADE methodology. Discussion : This study will help to guide clinical decision making when caring for adult patients with AHRF and improve our understanding of the limitations of the available literature assessing noninvasive oxygenation strategies in acute hypoxemic respiratory failure.

FACTORS OF NON-INVASIVE VENTILATION (NIV) FAILURE IN PATIENTS WITH ACUTE HYPOXEMIC RESPIRATORY FAILURE DUE TO SEVERE COMMUNITY ACQUIRED PNEUMONIA (CAP)

2018 ◽  
Vol 28 (2) ◽  
pp. 469-475
Author(s):  
Viktoria Ilieva ◽  
Yordanka Yamakova ◽  
Rossen Petkov ◽  
Georgi Yankov
Keyword(s):  
Respiratory Failure ◽  
Strong Association ◽  
The Other ◽  
Close Monitoring ◽  
Failure Rates ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure ◽  
Arterial Blood ◽  
Saps Ii Score ◽  
Protective Ventilation Strategy

Background: NIV is recommended as a first line of treatment for acute hypercapnic respiratory failure even in patients with acidosis. On the other hand, experts have a controversial opinion when it comes to a NIV trial for acute hypoxemic respiratory failure. Most of them don’t recommend NIV in severely hypoxemic patients because many studies report failure rates from 20 to 70,3% in this particular setting. Over the years, the use of NIV for acute hypoxemic respiratory failure has increased and the failure rates have dropped, mainly because clinicians make better patient selection and they are more aware of the factors, indicating pending NIV failure.Aim: The aim of our study is do determine the NIV failure rate in a cohort of patients with severe CAP, treated in an intensive care unit (ICU) of a specialized center for pulmonary diseases and to study the factors that are associated with NIV failure.Materials and methods: We studied a prospective cohort of 56 patients with severe CAP that developed acute hypoxemic respiratory failure and were put on NIV. 15 of them had pneumonia without ARDS; 9 – mild, 24 – moderate and 8 – severe ARDS. All of them were ventilated with pressure-supported modes (S, S/T, AVAPS) or CPAP only, taking into account the protective ventilation strategy. We recorded the patients’ age, CURB 65 and SAPS II score on admission and their heart rate (HR), respiratory rate (RR) and parameters of oxygenation, obtained from an arterial blood-gas analysis (ABG) on admission, 1 h and 24 h after initiation of NIV. Then we compared those parameters between patients that succeeded and those that failed an initial NIV trial.Results: Of all 56 patients, undergoing a NIV trial, only 8 (14%) failed and were intubated. 5 of them died in the ICU and the other 3 were extubated successfully. The reasons for NIV failure were: insufficient correction of hypoxemia in 6 patients, large leak in 1 and delirium in 2. After conducting a Mann-Whitney U test, we found statistically significant differences in age (median: 56,5; IQR: 18,5 vs. median: 67,5; IQR: 26,5; p=0,027), PaO2/FiO2 on the 1st (median: 161; IQR: 81,47 vs. median: 120,88; IQR: 50,13; p=0,039) and 24th hour (median: 183,56; IQR: 71,45 vs. median: 118,18; IQR: 56,47; p=0,011) after ventilation onset and HCO3 on admission (median: 23,59; IQR: 5,23 vs. median: 18,6; IQR: 7,15;p=0,006), on the 1st (median: 24,5; IQR: 5,33 vs. median: 20,35; IQR: 6,78, p=0,013) and 24th hour (median: 25,45; IQR: 7,13 vs. median: 21,6; IQR: 4,4; p=0,01) after ventilation onset between the groups of NIV success and failure. To investigate the strength of association between these parameters and NIV failure, we conducted a Kruskal-Wallis H statistical analysis and computed the correlation coefficient of Cohen W. It showed that all of the above listed factors have a strong association with NIV failure.Conclusion: In severe CAP with or without ARDS, causing acute hypoxemic respiratory failure, NIV can be a safe option for respiratory support with close monitoring of PaO2/FiO2 and HCO3, which may indicate upcoming failure.

scholarly journals Identification of persistent and resolving subphenotypes of acute hypoxemic respiratory failure in two independent cohorts

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Neha A. Sathe ◽  
Leila R. Zelnick ◽  
Carmen Mikacenic ◽  
Eric D. Morrell ◽  
Pavan K. Bhatraju ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Failure ◽  
Linear Models ◽  
Invasive Mechanical Ventilation ◽  
Respiratory Illness ◽  
High Morbidity ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure ◽  
Risk Of Death ◽  
Therapeutic Trials

Abstract Background Acute hypoxemic respiratory failure (HRF) is associated with high morbidity and mortality, but its heterogeneity challenges the identification of effective therapies. Defining subphenotypes with distinct prognoses or biologic features can improve therapeutic trials, but prior work has focused on ARDS, which excludes many acute HRF patients. We aimed to characterize persistent and resolving subphenotypes in the broader HRF population. Methods In this secondary analysis of 2 independent prospective ICU cohorts, we included adults with acute HRF, defined by invasive mechanical ventilation and PaO2-to-FIO2 ratio ≤ 300 on cohort enrollment (n = 768 in the discovery cohort and n = 1715 in the validation cohort). We classified patients as persistent HRF if still requiring mechanical ventilation with PaO2-to-FIO2 ratio ≤ 300 on day 3 following ICU admission, or resolving HRF if otherwise. We estimated relative risk of 28-day hospital mortality associated with persistent HRF, compared to resolving HRF, using generalized linear models. We also estimated fold difference in circulating biomarkers of inflammation and endothelial activation on cohort enrollment among persistent HRF compared to resolving HRF. Finally, we stratified our analyses by ARDS to understand whether this was driving differences between persistent and resolving HRF. Results Over 50% developed persistent HRF in both the discovery (n = 386) and validation (n = 1032) cohorts. Persistent HRF was associated with higher risk of death relative to resolving HRF in both the discovery (1.68-fold, 95% CI 1.11, 2.54) and validation cohorts (1.93-fold, 95% CI 1.50, 2.47), after adjustment for age, sex, chronic respiratory illness, and acute illness severity on enrollment (APACHE-III in discovery, APACHE-II in validation). Patients with persistent HRF displayed higher biomarkers of inflammation (interleukin-6, interleukin-8) and endothelial dysfunction (angiopoietin-2) than resolving HRF after adjustment. Only half of persistent HRF patients had ARDS, yet exhibited higher mortality and biomarkers than resolving HRF regardless of whether they qualified for ARDS. Conclusion Patients with persistent HRF are common and have higher mortality and elevated circulating markers of lung injury compared to resolving HRF, and yet only a subset are captured by ARDS definitions. Persistent HRF may represent a clinically important, inclusive target for future therapeutic trials in HRF.

scholarly journals Effect of Early vs. Delayed or No Intubation on Clinical Outcomes of Patients With COVID-19: An Observational Study

2020 ◽  
Vol 7 ◽  
Author(s):  
Ilias I. Siempos ◽  
Eleni Xourgia ◽  
Theodora K. Ntaidou ◽  
Dimitris Zervakis ◽  
Eleni E. Magira ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Failure ◽  
Observational Study ◽  
Clinical Outcomes ◽  
Controlled Trial ◽  
Invasive Mechanical Ventilation ◽  
Optimal Timing ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure ◽  
Early Intubation

Background: Optimal timing of initiation of invasive mechanical ventilation in patients with acute hypoxemic respiratory failure due to COVID-19 is unknown. Thanks to early flattening of the epidemiological curve, ventilator demand in Greece was kept lower than supply throughout the pandemic, allowing for unbiased comparison of the outcomes of patients undergoing early intubation vs. delayed or no intubation.Methods: We conducted an observational study including all adult patients with laboratory-confirmed COVID-19 consecutively admitted in Evangelismos Hospital, Athens, Greece between March 11, 2020 and April 15, 2020. Patients subsequently admitted in the intensive care unit (ICU) were categorized into the “early intubation” vs. the “delayed or no intubation” group. The “delayed or no intubation” group included patients receiving non-rebreather mask for equal to or more than 24 h or high-flow nasal oxygen for any period of time or non-invasive mechanical ventilation for any period of time in an attempt to avoid intubation. The remaining intubated patients comprised the “early intubation” group.Results: During the study period, a total of 101 patients (37% female, median age 65 years) were admitted in the hospital. Fifty-nine patients (58% of the entire cohort) were exclusively hospitalized in general wards with a mortality of 3% and median length of stay of 7 days. Forty-two patients (19% female, median age 65 years) were admitted in the ICU; all with acute hypoxemic respiratory failure. Of those admitted in the ICU, 62% had at least one comorbidity and 14% were never intubated. Early intubation was not associated with higher ICU-mortality (21 vs. 33%), fewer ventilator-free days (3 vs. 2 days) or fewer ICU-free days than delayed or no intubation.Conclusions: A strategy of early intubation was not associated with worse clinical outcomes compared to delayed or no intubation. Given that early intubation may presumably reduce virus aerosolization, these results may justify further research with a randomized controlled trial.

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