scholarly journals Implementation of noninvasive neurally adjusted ventilatory assist in pediatric acute respiratory failure: a controlled before-after quality improvement study

2021 ◽  
Vol 1 (1) ◽  
Author(s):  
Giovanna Chidini ◽  
Daniele De Luca ◽  
Edoardo Calderini ◽  
Stefano Scalia Catenacci ◽  
Tiziana Marchesi ◽  
...  
Keyword(s):  
Respiratory Failure ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Neurally Adjusted Ventilatory Assist ◽  
Intubation Rate ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure ◽  
Implementation Phase ◽  
Ventilatory Assist ◽  
Improve Patient

Abstract Backgrounds Pediatric noninvasive neurally adjusted ventilatory assist (NIV-NAVA) has been shown to improve patient-ventilator interaction but no data on clinical outcomes are available. Aim of this study was to compare NIV-NAVA with noninvasive pressure support (NIV-PS) in children with acute hypoxemic respiratory failure (AHRF), in a single-center before-after study. A cohort of thirty-four NIV-PS patients (before group) admitted to our PICU within the 2 years prior NAVA introduction was compared with a cohort of thirty children treated with NIV-NAVA during implementation phase (after group). The primary end-point was intubation rate between groups. Days on mechanical ventilation, number of invasive devices, nosocomial infections, PICU/hospital length of stay (LOS), and physiological parameters at 2 and 24 h after admission were considered. Results Intubation rate was lower in the NIV-NAVA group as compared to the NIV-PS group (p = 0.006). Patients treated with NIV-NAVA required fewer invasive devices (p = 0.032) and had lower incidence of ventilator-acquired pneumonia (p = 0.004) and shorter PICU (p = 0.032) and hospital LOS (p = 0.013). At 2 h, NIV-NAVA compared with NIV-PS resulted in higher paO2:FIO2 (p = 0.017), lower paCO2 (p = 0.002), RR (p = 0.026), and HR (p = 0.009). Conclusions Early NIV-NAVA vs NIV-PS was associated to lower intubation rate and shorter PICU and hospital LOS. Further studies are needed in order to confirm these preliminary data.

scholarly journals High-flow nasal oxygen reduces endotracheal intubation: a randomized clinical trial

2020 ◽  
Vol 14 ◽  
pp. 175346662095645
Author(s):  
Ricardo Andino ◽  
Gema Vega ◽  
Sandra Karina Pacheco ◽  
Nuria Arevalillo ◽  
Ana Leal ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Respiratory Failure ◽  
Endotracheal Intubation ◽  
Oxygen Therapy ◽  
High Flow ◽  
Hospital Length Of Stay ◽  
Control Group ◽  
Number Needed To Treat ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure

Background: The benefits of high-flow nasal cannula (HFNC) as primary intervention in patients with acute hypoxemic respiratory failure (AHRF) are still a matter in debate. Our objective was to compare HFNC therapy versus conventional oxygen therapy (COT) in the prevention of endotracheal intubation in this group of patients. Methods: An open-label, controlled and single-centre clinical trial was conducted in patients with severe AHRF, defined by a PaO2/FIO2 ratio ⩽200, to compare HFNC with a control group (CG) treated by COT delivered through a face mask, with the need to perform intubation as the primary outcome. The secondary outcomes included tolerance of the HFNC device and to look for the predictive factors for intubation in these patients. Results: A total of 46 patients were included (22 in the COT group and 24 in the HFNC group) 48% of whom needed intubation: 63% in the COT group and 33% in the HFNC group, with significant differences both in intention to treat [χ2 = 4.2; p = 0.04, relative risk (RR) = 0.5; confidence interval (CI) 95%: 0.3–1.0] and also in treatment analysis (χ2 = 4.7; p = 0.03; RR = 0.5; IC 95%: 0.3–0.9) We obtained a number needed to treat (NNT) = 3 patients treated to avoid an intubation. Intubation occurred significantly later in the HFNC group. Estimated PaO2/FIO2, respiratory rate and dyspnea were significantly better in the HFNC group. Patients treated with HFNC who required intubation presented significant worsening after the first 8 h, as compared with non-intubated HFNC group patients. Mortality was 22% with no differences. The HFNC group patients were hospitalized for almost half of the time in the intensive care unit (ICU) and in the ward, with significantly less hospital length of stay. A total of 14 patients in the HFNC group (58%) complained of excessive heat and 17% of noise; 3 patients did not tolerate HFNC. Conclusion: Patients with severe acute hypoxemic respiratory failure who tolerate HFNC present a significantly lower need for endotracheal intubation compared with conventional oxygen therapy. Clinical Trial Register EUDRA CT number: 2012-001671-36 The reviews of this paper are available via the supplemental material section.

scholarly journals Awake prone positioning in non-intubated patients with acute hypoxemic respiratory failure due to COVID-19: a systematic review and meta-analysis

2021 ◽  
Author(s):  
Ivan Pavlov ◽  
Hangyong He ◽  
Bairbre McNicholas ◽  
Yonatan Perez ◽  
Elsa Tavernier ◽  
...  
Keyword(s):  
Systematic Review ◽  
Respiratory Failure ◽  
Observational Studies ◽  
Meta Analysis ◽  
Current Evidence ◽  
Intubation Rate ◽  
Prone Positioning ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure ◽  
Randomized Controlled

Abstract Background: Awake prone positioning (APP) has been advocated to improve oxygenation and prevent intubations of patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). This paper aims to synthesize the available evidence on the efficacy of APP.Methods: We performed a systematic review and meta-analysis of observational studies to compare oxygenation parameters in-hospital intubation rate in patients treated with APP or with standard care.Results: A total of 46 published and 4 unpublished observational studies that included 2994 patients were included. APP was associated with significant improvement of various oxygenation parameters in 19 studies (n=381) that reported this outcome. The intubation rate was 27% (95%CI, 19 to 37%) in the 870 patients treated with APP, as compared to 30% (95%CI, 20 to 42%) in the 852 patients treated with usual care (p=0.71).Conclusions: On the basis of the available evidence, it is not possible to demonstrate efficacy of APP for patients with COVID-19 acute respiratory failure, as assessed by the need for invasive ventilation. Routine implementation of APP outside of a clinical trial is not supported by current evidence. Randomized controlled clinical studies are urgently needed to definitively assess the utility of APP in these patients.Registered on PROSPERO on August 3d, 2020, CRD42020201947.

scholarly journals Inhaled nitric oxide use in COVID19-induced hypoxemic respiratory failure.

2021 ◽  
Author(s):  
Abhishek R. Giri ◽  
Siva Naga S. Yarrarapu ◽  
Nirmaljot Kaur ◽  
Alexander P. Hochwald ◽  
Julia Crook ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Failure ◽  
Patient Outcomes ◽  
Invasive Mechanical Ventilation ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Hypoxemic Respiratory Failure ◽  
The Mean ◽  
Group 2 ◽  
Group 1

Introduction: Nitric Oxide (NO) is an endogenous vasodilator that is synthesized by the vascular endothelium. Due to its vasodilatory effect and short half-life, the use of NO as an exogenous inhaled medication (iNO) to target the pulmonary vasculature, in conditions with increased pulmonary vascular resistance, has been studied. The use of iNO in patients with ARDS secondary to COVID-19 has therapeutic importance in improving oxygenation. It also has potential anti-viral, anti-inflammatory, and anti-thrombotic properties. Herein, we want to share our experience of use of iNO in hypoxemic respiratory failure secondary to COVID 19 pneumonia. We hypothesized that iNO may be beneficial at preventing intubation, decreasing invasive mechanical ventilation duration, and consequently improve outcomes including hospital mortality. Methods: This is a descriptive hypothesis generating study of patients admitted for COVID-19 pneumonia who received iNO for hypoxemic respiratory failure, at a single tertiary care center. We collected information on patient demographics, co-morbidities, iNO treatment, need for intubation, arterial blood gas analysis, laboratory values, hospital length of stay, and mortality. Patients were divided into two groups based on the timing of iNO administration: group 1 - pre-intubation (i.e. iNO started at least 1 day prior to endotracheal intubation, if any) and group 2 - post-intubation (i.e. iNO started on the same day as or after endotracheal intubation and mechanical ventilation). Result: A total of 45 (group 1, n=26 [57.8%] vs group2, n=19 [42.2%]) COVID 19 patients who had iNO use. The mean time from hospital admission to iNO administration(days) in group 1 was 2.1 (1.8, SD) vs 4.2 (5.9, SD) in group 2. The mean hospital length of stay from the beginning of iNO treatment until discharge or death was 18.3 vs 26.2 days, with 8 deaths (30.8%) vs 9 deaths (47.4%) in group 1 vs group 2, respectively. Discussion: Our study is unable to demonstrate comparably outcomes benefit of iNO. Although there was a trend towards decreased need for invasive mechanical ventilation in group 1[Only 11 (42.3 %) patients were intubated out of 26 who received iNO early after hospital admission (2.3 days)], no statistical significance could be achieved because of small sample size. Our study demonstrated that iNO administration pre-intubation did not appear harmful and appears to be safe, complementary to HFNC, signalling the domain where systematic investigation is required to confirm or not the potential for iNO to improve patient outcomes in the management of COVID 19-induced hypoxemic respiratory failure. Conclusion: This study showcases the potential benefit of early pre-intubation use of iNO in COVID patients with hypoxemic respiratory failure. This study could conclusively form the basis for a prospective trial and could have a tremendous impact in improving patient outcomes.

scholarly journals Early versus late awake prone positioning in non-intubated patients with COVID-19

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Ramandeep Kaur ◽  
David L. Vines ◽  
Sara Mirza ◽  
Ahmad Elshafei ◽  
Julie A. Jackson ◽  
...  
Keyword(s):  
Respiratory Failure ◽  
Controlled Trial ◽  
Primary Objective ◽  
Intubation Rate ◽  
Prone Positioning ◽  
High Flow Nasal Cannula ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure ◽  
Randomized Controlled ◽  
Post Hoc

Abstract Background Awake prone positioning (APP) is widely used in the management of patients with coronavirus disease (COVID-19). The primary objective of this study was to compare the outcome of COVID-19 patients who received early versus late APP. Methods Post hoc analysis of data collected for a randomized controlled trial (ClinicalTrials.gov NCT04325906). Adult patients with acute hypoxemic respiratory failure secondary to COVID-19 who received APP for at least one hour were included. Early prone positioning was defined as APP initiated within 24 h of high-flow nasal cannula (HFNC) start. Primary outcomes were 28-day mortality and intubation rate. Results We included 125 patients (79 male) with a mean age of 62 years. Of them, 92 (73.6%) received early APP and 33 (26.4%) received late APP. Median time from HFNC initiation to APP was 2.25 (0.8–12.82) vs 36.35 (30.2–75.23) hours in the early and late APP group (p < 0.0001), respectively. Average APP duration was 5.07 (2.0–9.05) and 3.0 (1.09–5.64) hours per day in early and late APP group (p < 0.0001), respectively. The early APP group had lower mortality compared to the late APP group (26% vs 45%, p = 0.039), but no difference was found in intubation rate. Advanced age (OR 1.12 [95% CI 1.0–1.95], p = 0.001), intubation (OR 10.65 [95% CI 2.77–40.91], p = 0.001), longer time to initiate APP (OR 1.02 [95% CI 1.0–1.04], p = 0.047) and hydrocortisone use (OR 6.2 [95% CI 1.23–31.1], p = 0.027) were associated with increased mortality. Conclusions Early initiation (< 24 h of HFNC use) of APP in acute hypoxemic respiratory failure secondary to COVID-19 improves 28-day survival. Trial registration ClinicalTrials.gov NCT04325906.

scholarly journals High-Flow Nasal Cannula Treatment in Patients with COVID-19 Acute Hypoxemic Respiratory Failure

2020 ◽  
Author(s):  
Mohammed S Alshahrani ◽  
Hassan M. Alshaqaq ◽  
Jehan Alhumaid ◽  
Ammar A. Binammar ◽  
Khalid H AlSalem ◽  
...  
Keyword(s):  
Respiratory Failure ◽  
Sofa Score ◽  
High Flow ◽  
Nasal Cannula ◽  
Hospital Length Of Stay ◽  
High Flow Nasal Cannula ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure ◽  
Risk Of Death ◽  
Tertiary Teaching

Abstract BackgroundThe increasing burden of coronavirus disease 2019 (COVID-19)-related acute hypoxemic respiratory failure (AHRF) is straining intensive care unit (ICU) resources globally. Early use of high-flow nasal cannula (HFNC) decreases the need for endotracheal intubation (EI) in different causes of respiratory failure. While HFNC is used in COVID-19-related AHRF, its efficacy remains to be investigated. We aimed to examine whether the use of high-flow nasal oxygen therapy (HFNO) prevents the need for intubation in COVID-19 with (AHRF).MethodsThis is a single-center prospective observational study that was conducted at a tertiary teaching hospital in Saudi Arabia the period from April, 2020 to August, 2020. Adults patients admitted to the ICU with AHRF secondary to COVID-19 pneumonia and managed with HFNC were included. We excluded hemodynamically unstable patients and those who were intubated or managed with non-invasive ventilation. Patients’ data and clinical outcomes were pre-defined. The primary outcome was to determine the rate of EI among patients who were treated with HFNC. Secondary outcomes included predictors of HFNC success/failure, mortality, and hospital length of stay. ResultsWe consecutively screened 111 hospitalized COVID-19 patients with AHRF,. Out of those, 44 (40%) patients received HFNC with a median duration of three days (IQR, 1–5). The median age was 57 years (interquartile range [IQR], 46–64), and 82% were men. HFNC failure and EI occurred in 29 (66%) patients. Patients who failed HFNC treatment had higher risk of death compared to those who did not (52% vs. 0%; p=0.001). At baseline, the prevalence of hypertension, chronic kidney disease, and asthma was higher in the HFNC failure group. After adjustment for possible confounders, a high Sequential Organ Failure Assessment (SOFA) score and a low ROX index were significantly associated with HFNC failure (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.04–1.93; p=0.025; and HR, 0.61; 95% CI, 0.42–0.88; p=0.008, respectively). ConclusionsIn this prospective study, one-third of hypoxemic COVID-19 patients who received HFNC did not require intubation. High SOFA score and low ROX index were associated with HFNC failure.

scholarly journals Non-invasive ventilation for acute hypoxemic respiratory failure: intubation rate and risk factors

Critical Care ◽  
2013 ◽  
Vol 17 (6) ◽  
pp. R269 ◽  
Author(s):  
Arnaud W Thille ◽  
Damien Contou ◽  
Chiara Fragnoli ◽  
Ana Córdoba-Izquierdo ◽  
Florence Boissier ◽  
...  
Keyword(s):  
Risk Factors ◽  
Respiratory Failure ◽  
Intubation Rate ◽  
Invasive Ventilation ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure ◽  
Non Invasive ◽  
Non Invasive Ventilation

scholarly journals The efficacy and tolerance of prone positioning in non-intubation patients with acute hypoxemic respiratory failure and ARDS: a meta-analysis

2021 ◽  
Vol 15 ◽  
pp. 175346662110094
Author(s):  
Wei Tan ◽  
Dong-yang Xu ◽  
Meng-jiao Xu ◽  
Zan-feng Wang ◽  
Bing Dai ◽  
...  
Keyword(s):  
Respiratory Failure ◽  
Mortality Rate ◽  
Respiratory Rate ◽  
Meta Analysis ◽  
Controlled Trials ◽  
Intubation Rate ◽  
Prone Positioning ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure ◽  
Non Invasive

Background and aims: The application of prone positioning with acute hypoxemic respiratory failure (AHRF) or acute respiratory distress syndrome (ARDS) in non-intubation patients is increasing gradually, applying prone positioning for more high-flow nasal oxygen therapy (HFNC) and non-invasive ventilation (NIV) patients. This meta-analysis evaluates the efficacy and tolerance of prone positioning combined with non-invasive respiratory support in patients with AHRF or ARDS. Methods: We searched randomized controlled trials (RCTs) (prospective or retrospective cohort studies, RCTs and case series) published in PubMed, EMBASE and the Cochrane Central Register of Controlled Trials from 1 January 2000 to 1 July 2020. We included studies that compared prone and supine positioning with non-invasive respiratory support in awake patients with AHRF or ARDS. The meta-analyses used random effects models. The methodological quality of the RCTs was evaluated using the Newcastle–Ottawa quality assessment scale. Results: A total of 16 studies fulfilled selection criteria and included 243 patients. The aggregated intubation rate and mortality rate were 33% [95% confidence interval (CI): 0.26–0.42, I2 = 25%], 4% (95% CI: 0.01–0.07, I2 = 0%), respectively, and the intolerance rate was 7% (95% CI: 0.01–0.12, I2 = 5%). Prone positioning increased PaO2/FiO2 [mean difference (MD) = 47.89, 95% CI: 28.12–67.66; p < 0.00001, I2 = 67%] and SpO2 (MD = 4.58, 95% CI: 1.35–7.80, p = 0.005, I2 = 97%), whereas it reduced respiratory rate (MD = −5.01, 95% CI: −8.49 to −1.52, p = 0.005, I2 = 85%). Subgroup analyses demonstrated that the intubation rate of shorter duration prone (⩽5 h/day) and longer duration prone (>5 h/day) were 34% and 21%, respectively; and the mortality rate of shorter duration prone (⩽5 h/day) and longer duration prone (>5 h/day) were 6% and 0%, respectively. PaO2/FiO2 and SpO2 were significantly improved in COVID-19 patients and non-COVID-19 patients. Conclusion: Prone positioning could improve the oxygenation and reduce respiratory rate in both COVID-19 patients and non-COVID-19 patients with non-intubated AHRF or ARDS. The reviews of this paper are available via the supplemental material section.

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