Significant Improvement In Oxygenation Research Articles

Biological impact of manual blood exchange in malignant Bordetella pertussis infection in infants.

Manual blood exchange (MBE) is a leukoreduction therapy for hyperleukocytosis in Bordetella spp. We describe the impact of BE on clinical and biological parameters in critically ill children with malignant pertussis. This is a monocentric retrospective review of patients with malignant pertussis infection treated with MBE. It describes the evolution of haemodynamic, ventilatory, haematologic and metabolic characteristics before and after MBE. Between January 2006 and December 2021, nine patients (median age 43 days, range: 13-80 days) had 16 MBE for malignant pertussis. All patients were mechanically ventilated, and 7/9 patients developed pulmonary hypertension during their paediatric intensive care unit (PICU) stay. Overall, 3/9 patients survived, and the mean PICU length of stay was 8.5 days (range: 1-52 days). We found a significant reduction of the leukocyte count (pre-MBE: 61.8 G/L [interquartile range (IQR): 55.8-74.8] vs. post-MBE: 19.4 G/L [IQR: 17.7-24.1]; p ≤ 0.001) and significant oxygenation improvement (pre-MBE SpO2/FiO2: 190 [IQR: 106-200] vs. post-MBE SpO2/FiO2: 242 [IQR: 149-250]; p = 0.03). The main side effects were a significant reduction of thrombocytes (pre-MBE: 411 G/L [IQR: 166.5-563.5] vs. post-MBE: 66 G/L [IQR: 46-82.5]; p = <0.001) and of ionized calcium (iCa) (pre-MBE iCa: 1.3 [IQR: 1.22-1.37] vs. post-MBE iCa: 1.25 [IQR: 1.85-2.24]; p = 0.03). MBE efficiently reduces leukocytes and improves oxygenation in severe Bordetella pertussis infection in infants. Careful monitoring of calcium and thrombocytes seems mandatory.

Vasopressin as adjunctive therapy in pulmonary hypertension associated with refractory systemic hypotension in term newborns.

The use of vasopressin as an adjunctive therapy in pulmonary hypertension associated with refractory systemic hypotension has increased. The objective of our study is to describe its effects on term infants. Retrospective observational study. Setting in a referral level IV neonatal intensive care unit from a middle-income region. The patients are term neonates admitted to our NICU who required vasopressin due to severe Pulmonary Hypertension and refractory hypotension during a 49-month period (December 2019 and December 2023). We identified 68 term infants, all in mechanical ventilation, receiving inhaled nitric oxide (iNO), and a phased protocol management for hypotension. Vasopressin was a started at a mean of 2 days with a mean duration of 80 h. Regarding hemodynamic outcome: diastolic, systolic, and median systemic pressure significantly increased during the first 4 h of treatment, as well as arterial pH and urine output. Accordingly, lactate and Vasoactive Inotropic Score (VIS) score decreased after 4 and 8 h, respectively, after vasopressin was started. Regarding oxygenation markers: oxygen requirements and mean airway pressure decreased significantly (and therefore the oxygenation index decreased in concordance) after 4 h of vasopressin. Echocardiographic indices of pulmonary hypertension progressively improved after vasopressin infusion with a significant decrease of tricuspid ingurgitation velocities and the rate of right-to- left ductal shunt through the ductus arteriosus. In the same way, left and right ventricular output increased after the initiation of vasopressin. This study showed that the use of vasopressin in neonates with persistent pulmonary hypertension was associated with a rapid and significant improvement in oxygenation and hemodynamic markers of perfusion, including blood pressure. Its effects begin early during the first hours of treatment.

High Frequency Oscillatory Ventilation (HFOV) and Inhaled Nitric Oxide (iNO) Use During Neonatal Emergency Transport - Feasibility and Efficacy in India.

A retrospective studyof 24 neonates to evaluate the feasibility and efficacy of high frequency oscillatory ventilation (HFOV) and inhaled nitric oxide (iNO) for transferring critically ill neonates to tertiary neonatal intensive care, who were transported by road ambulance was done. Efficacy was measured by clinical improvement, patient safety was assessed by comparing cardiorespiratory indicators before and after transport, and adverse events during transport. Significant oxygenation improvement was observed in neonates transported with HFOV ± iNO compared to earlier ventilator settings. Pre- and post-transport vital signs were stable, and no transport-related deaths occurred. A substantial rise in median SpO2 was seen after transfer [86 (81, 91) vs. 93 (89, 97) before transport, p <0.001]. Twelve of twenty-one newborns who received nitric oxide demonstrated significant improvement in oxygenation index (a 10% decrease from prior value). Overall survival was 70.8%, however non-transfer or inadequate respiratory treatment may have exacerbated mortality.

Prone position in severe hypoxemia in patients with covid-19 during venovenous ECMO, does the number of cycles matter?

Extracorporeal membrane oxygenation (ECMO) support has been known to be beneficial in cases of severe Adult Respiratory Distress Syndrome (ARDS). The increase in such cases results in an increase in scenarios of severe hypoxemia even during an ECMO run. The purpose of this study was to evaluate the benefit of the prone position (PP) in an analytical observational retrospective cohort study. The study included adult patients with ARDS, caused as a result of SARS-CoV-2, undergoing PP during ECMO support in the period from 2020 to 2021. Thirty-five patients were placed in PP with an average of 3.6 cycles per patient. The group of patients undergoing &gt;3 PP cycles had a significant improvement in oxygenation during PP, 𝑃𝑎𝑂2 (60.13 vs. 66.15, mmHg p = 0.0065) and 𝑃𝑎𝑂2⁄𝐹𝑖𝑂2 (136 vs. 155, p = 0.0026). After adjusting for confounding variables (age, RESP score, and days from the start of ECMO and the first cycle of PP), the group with &gt;3 cycles showed a hazard ratio of 0.2 (95% confidence interval, 0.051–0.78; p = 0.02). The study outcomes confirmed the benefits of PP as a strategy against severe hypoxemia in ECMO, and evaluated variables such as the number of cycles, which may be associated with improved survival in this subgroup of critically ill patients.

Response to prone positioning in COVID-19 patients with acute respiratory distress syndrome: a retrospective observational study

BackgroundCOVID-19 pneumonia and respiratory failure are the leading causes of death in COVID-19 patients. Prone positioning was hypothesized to improve oxygenation in ARDS patients and is being studied in COVID-19, but the current evidence is still unclear regarding survival and hospitalization. We aimed to investigate the effect of prone positioning on oxygenation in patients with COVID-19 pneumonia and ARDS and to examine the factors associated with better/worse outcomes.MethodsA retrospective record-based cohort study included all confirmed COVID-19 patients with pneumonia and ARDS who underwent prone positioning admitted to King Fahad Hospital, Medina, Saudi Arabia, during 2020–2021.ResultsThis study included 75 cases (mean age 60.3 ± 15.7 year, 50 (66.7%) males), and all fulfilled the definition of ARDS. There was a significant improvement in oxygenation (PaO2 and PaO2/FIO2) following prone positioning (53.5 ± 6.8 vs. 60.4 ± 8.2 mmHg, p < 0.001 for PaO2 supine and prone and 120.3 ± 35 vs. 138 ± 40.2, p < 0.001 for PaO2/FIO2 supine and prone respectively). There was no significant difference in age, gender, smoking, or number of comorbidities between survivors and non-survivors. Survivors had significantly higher baseline PaO2 (p 0.018) and PF ratio (p 0.001) compared to non-survivors. They had also less severe inflammation and organ damage observed as significantly lower ferritin (p 0.001), D-dimer (p 0.026), aspartate aminotransferase (p 0.02), urea (p 0.032), creatinine (p 0.001), and higher platelet counts (p 0.001). Intubation and high-moderate comorbidity risk categories were associated with non-survival (p 0.001 and p 0.014, respectively).ConclusionProne positioning is useful in the improvement of oxygenation in intubated and awake patients with COVID-19 pneumonia and ARDS. Intubation and high comorbidity risk categories were associated with non-survival.

PEEP-Induced Lung Recruitment Maneuver Combined with Prone Position for ARDS: A Single-Center, Prospective, Randomized Clinical Trial

Background: Prone position (PP) and the positive end-expiratory pressure (PEEP)-induced lung recruitment maneuver (LRM) are both efficient in improving oxygenation and prognosis in patients with ARDS. The synergistic effect of PP combined with PEEP-induced LRM in patients with ARDS remains unclear. We aim to explore the effects of PP combined with PEEP-induced LRM on prognosis in patients with moderate to severe ARDS and the predicting role of lung recruitablity. Methods: Patients with moderate to severe ARDS were consecutively enrolled. The patients were prospectively assigned to either the intervention (PP with PEEP-induced LRM) or control groups (PP). The clinical outcomes, respiratory mechanics, and electric impedance tomography (EIT) monitoring results for the two groups were compared. Lung recruitablity (recruitment-to-inflation ratio: R/I) was measured during the PEEP-induced LRM procedure and was used for predicting the response to LRM. Results: Fifty-eight patients were included in the final analysis, among which 28 patients (48.2%) received PEEP-induced LRM combined with PP. PEEP-induced LRM enhanced the effect of PP by a significant improvement in oxygenation (∆PaO2/FiO2 75.8 mmHg vs. 4.75 mmHg, p &lt; 0.001) and the compliance of respiratory system (∆Crs, 2 mL/cmH2O vs. −1 mL/cmH2O, p = 0.02) among ARDS patients. Based on the EIT measurement, PP combined with PEEP-induced LRM increased the ventilation distribution mainly in the dorsal region (5.0% vs. 2.0%, p = 0.015). The R/I ratio was measured in 28 subjects. The higher R/I ratio was related to greater oxygenation improvement after LRM (Pearson’s r = 0.4; p = 0.034). Conclusions: In patients with moderate to severe ARDS, PEEP-induced LRM combined with PP can improve oxygenation and dorsal ventilation distribution. R/I can be useful to predict responses to LRM.

Efficacy and safety of phospholipid nanoparticles (VBI-S) in reversing intractable hypotension in patients with septic shock: a multicentre, open-label, repeated measures, phase 2a clinical pilot trial

Since the 1990's attempts to favorably modulate nitric oxide (NO) have been unsuccessful. We hypothesized that because NO is lipophilic it would preferentially localize into intravascularly infused hydrophobic nanoparticles, thereby reducing its bioavailability and adverse effects without inhibiting its production. We aimed to determine the efficacy and safety of intravenous infusion of a fluid comprised of hydrophobic phospholipid nanoparticles (VBI-S) that reversibly absorb NO in the treatment of hypotension of patients in severe septic shock. This is a multicentre, open-label, repeated measures, phase 2a clinical pilot trial done at six hospital centers in the USA. Patients in severe septic shock were enrolled after intravenous fluid therapy had failed to raise mean arterial blood pressure (MAP) to at least the generally accepted level of 65mmHg, requiring the use of vasopressors. The primary endpoint of this study is the proportion of patients in whom MAP increased by at least 10mmHg. VBI-S was administered intravenously to patients as boluses of 100ml, 200ml, 400ml, and 800ml at 999ml/min until the blood pressure goal was reached after which the infusion was stopped, and the MAP was recorded. All patients who received any volume of VBI-S were included in the primary and safety analysis. The study is registered with ClinicalTrials.gov, NCT04257136. Between February 17, 2020 and January 3, 2023, 20 eligible patients were enrolled in the study. In all 20 (100%) patients, the goal of increasing MAP by at least 10mmHg using VBI-S was achieved (p=0.0087, effect size=0.654). Mean VBI-S volume required to meet the primary goal was 561.0±372.3ml. The goal of lowering vasopressor dose was also achieved (p=0.0017). Within 48h or less after VBI-S, there was a statistically significant improvement in oxygenation, serum creatinine, clotting variables, procalcitonin, lactic acid, and the sequential organ failure assessment (SOFA) score. At 24h and 48h following administration of VBI-S, 12/15 (80%) and 9/12 (75%) patients developed hyperlipidemia, respectively. No severe adverse events of VBI-S were observed, and there were no treatment-related deaths. These preliminary findings suggest the safety and efficacy of VBI-S in treating hypotension in patients with septic shock. However, a definitive mortality benefit cannot be demonstrated without a randomized controlled study. The Naval Medical Research Command-Naval Advanced Medical Development program via the Medical Technology Enterprise Consortium.

Effect of Sildenafil in Neonates with Persistent Pulmonary Hypertension: An Interventional Study

Introduction: Persistent Pulmonary Hypertension of the Newborn (PPHN) reflects a disruption of the normal perinatal circulatory transition and is characterised by high pulmonary artery pressure. Inhaled Nitric Oxide (iNO) is considered the mainstay of treatment for PPHN. However, many developing and resource limited countries do not have access to such expensive therapy. Therefore, sildenafil, due to its easy availability and low cost, becomes the most commonly used drug in the management of PPHN in such settings. Aim: To study the treatment response and outcomes of neonates who received sildenafil for the management of PPHN. Materials and Methods: The present hospital-based prospective interventional study was conducted in the Neonatal Intensive Care Unit (NICU), BJ Medical College, Civil Hospital, Ahmedabad, Gujarat, between May 1, 2020, and April 30, 2021. Study was conducted on neonates with meconium aspiration syndrome and/or severe birth asphyxia admitted to the NICU. A total of 48 neonates with Two Dimensional (2D) echocardiography-proven PPHN were enrolled. Baseline clinical parameters including heart rate, respiratory rate, preductal and postductal Saturation of Peripheral Oxygen (SpO2), Oxygenation Index (OI), Saturation Oxygen Distending Pressure Index (SOPI), and Non Invasive Blood Pressure (NIBP) were monitored every six hours. Neonates who were on invasive/ non invasive ventilation had their Fraction of Inspired Oxygen (FiO2), Positive End Expiratory Pressure (PEEP), Peak Inspiratory Pressure (PIP), respiratory rate and flow rate monitored every six hours. Data were statistically analysed using Analysis of Variance (ANOVA) test. Results: During the study period, a total of 1080 neonates were admitted with meconium aspiration syndrome and/or severe birth asphyxia, out of which 48 neonates showed findings suggestive of PPHN on 2D echocardiography. A statistically significant improvement in oxygenation after sildenafil treatment was indicated by a significant reduction in OI from 35.3±8.6 to 13.2±2.1 (p-value&lt;0.001), a reduction in SOPI from 3.6±0.3 to 1.5±0.2 (p-value&lt;0.001), a reduction in FiO2 (%) from 94.6±8.19 to 24.2±4.5 (p-value&lt;0.001), an increase in Partial pressure of oxygen (PaO2) (mmHg) from 52±5.6 to 72±3.4 (p-value&lt;0.001), and an increase in SpO2 (%) from 83.5±8.6 to 93.5±5.1 (p-value&lt;0.001). Conclusion: The findings of the present study suggest that oral sildenafil can be successfully used to improve oxygenation in patients with PPHN, especially in a resource limited setting where facilities like Extracorporeal Membrane Oxygenation (ECMO) and iNO are not available, as demonstrated in the present study.

Flow Grade-Based Success Rates, Complication Rates, and Balloon Pulmonary Angioplasty Patency for Total Occlusions

BackgroundThe number of successfully recanalized total occlusions affects hemodynamic improvement after balloon pulmonary angioplasty (BPA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to clarify the current efficacy, patency, and success rate of BPA for total occlusions. MethodsBetween April 2016 and August 2021, 178 BPAs were performed in 100 patients with CTEPH and total occlusions. The primary success and subsequent patency rates immediately before the second BPA procedure (follow-up) were compared between the segmental and subsegmental groups, based on the flow grade, which was defined as follows: 0, no reperfusion; 1, minimal reperfusion; 2, partial reperfusion; and 3, complete reperfusion. ResultsTotal occlusions were mainly located in the right lung (70%) and lower lobes (48%). The primary success rate was 88%, with significant improvements in oxygenation, hemodynamic parameters, and 6-minute walk test. The primary flow grade did not differ between groups. However, the proportion of lesions with a flow grade of 2 or 3 at follow-up was significantly higher in the subsegmental group than in the segmental group (84% vs 45%, respectively; P < 0.01). In multivariate analysis, flow grade in the acute phase (odds ratio [OR], 46.9; 95% confidence interval [CI], 12.54-176.78; P < 0.01) and subsegmental lesions (OR, 13.8; 95% CI, 3.24-58.94; P < 0.01) were independently associated with better patency (flow grade of 2 or 3) at follow-up. ConclusionsTotal occlusions can be safely and effectively treated with BPA. BPA for total occlusions may be preferable for subsegmental over segmental lesions.

A randomized controlled trial of nebulized surfactant for the treatment of severe COVID-19 in adults (COVSurf trial)

SARS-CoV-2 directly targets alveolar epithelial cells and can lead to surfactant deficiency. Early reports suggested surfactant replacement may be effective in improving outcomes. The aim of the study to assess the feasibility and efficacy of nebulized surfactant in mechanically ventilated COVID-19 patients. Patients were randomly assigned to receive open-labelled bovine nebulized surfactant or control (ratio 3-surfactant: 2-control). This was an exploratory dose–response study starting with 1080 mg of surfactant delivered at 3 time points (0, 8 and 24 h). After completion of 10 patients, the dose was reduced to 540 mg, and the frequency of nebulization was increased to 5/6 time points (0, 12, 24, 36, 48, and an optional 72 h) on the advice of the Trial Steering Committee. The co-primary outcomes were improvement in oxygenation (change in PaO2/FiO2 ratio) and ventilation index at 48 h. 20 patients were recruited (12 surfactant and 8 controls). Demographic and clinical characteristics were similar between groups at presentation. Nebulized surfactant administration was feasible. There was no significant improvement in oxygenation at 48 h overall. There were also no differences in secondary outcomes or adverse events. Nebulized surfactant administration is feasible in mechanically ventilated patients with COVID-19 but did not improve measures of oxygenation or ventilation.

Hemoadsorption as Adjuvant Therapy in Acute Respiratory Distress Syndrome (ARDS): A Systematic Review and Meta-Analysis.

Acute respiratory distress syndrome (ARDS) is often a consequence of a dysregulated immune response; therefore, immunomodulation by extracorporeal cytokine removal has been increasingly used as an adjuvant therapy, but convincing data are still missing. The aim of this study was to investigate the effects of adjunctive hemoadsorption (HA) on clinical and laboratory outcomes in patients with ARDS. We performed a systematic literature search in PubMed, Embase, CENTRAL, Scopus, and Web of Science (PROSPERO: CRD42022292176). The population was patients receiving HA therapy for ARDS. The primary outcome was the change in PaO2/FiO2 before and after HA therapy. Secondary outcomes included the before and after values for C-reactive protein (CRP), lactate, interleukin-6 (IL-6), and norepinephrine (NE) doses. We included 26 publications, with 243 patients (198 undergoing HA therapy and 45 controls). There was a significant improvement in PaO2/FiO2 ratio following HA therapy (MD = 68.93 [95%-CI: 28.79 to 109.06] mmHg, p = 0.005) and a reduction in CRP levels (MD = -45.02 [95%-CI: -82.64; -7.39] mg/dL, p = 0.026) and NE dose (MD = -0.24 [95%-CI: -0.44 to -0.04] μg/kg/min, p = 0.028). Based on our findings, HA resulted in a significant improvement in oxygenation and a reduction in NE dose and CRP levels in patients treated with ARDS. Properly designed RCTs are still needed.

Efficacy of baricitinib in severe coronavirus disease 2019

Abstract Background Coronavirus disease 2019 (COVID-19) binds to angiotensin-converting enzyme through a viral spike protein prompting an inflammatory cascade. Baricitinib, an oral drug, is a selective inhibitor of Janus kinase (JAK) 1 and 2 and interferes with the intracellular signaling pathway of many cytokines and in combination with remdesivir may give good results in severe COVID-19 infection. Aim The aim was to assess the effect of baricitinib in severe COVID-19 pneumonia. Patients and methods A total of 30 patients with SARS-CoV-2-confirmed positive cases by nasopharyngeal swab/reverse transcriptase PCR with severe pneumonia received oral baricitinib 4 mg daily, and patients were followed for at least 14 days, unless previously discharged or dead. Results Patients were admitted to the ICU, with a mean duration of 11 days. All patients received high-flow oxygen with nonrebreathing mask. A total of 18 (60%) patients improved and 12 (40%) patients died. Moreover, 15 patients had comorbidities, and mortality was high in this group (10 patients). No serious adverse effects of baricitinib were detected in our study. All patients were hypoxic at admission. The mean oxygen saturation on room air was 70%. There was a statistically significant improvement in oxygenation on discharge after receiving treatment, with mean oxygen saturation of 90% on room air. Conclusion Baricitinib with remdesivir improves clinical status and oxygen saturation in patients with severe COVID-19 pneumonia with no serious adverse effects.

A negative trial for vasoactive intestinal peptide in COVID-19-associated acute hypoxaemic respiratory failure

A negative trial for vasoactive intestinal peptide in COVID-19-associated acute hypoxaemic respiratory failure

Nebulized Heparin to Reduce COVID-19-induced Acute Lung Injury: A Prospective Observational Study.

High mortality due to COVID-19 disease has been a serious concern, a few of the causes being disseminated intravascular coagulation (DIC) and venous thromboembolism. Considering this, some experts have used heparin. However, its role still needs to be validated. This study predicts the role of nebulized heparin in decreasing the severity of lung injury caused by COVID-19. Thirty patients admitted with COVID-19 acute respiratory distress syndrome (ARDS) in the intensive care unit (ICU) of All India Institute of Medical Sciences, Rishikesh, were included in this study, which was conducted over a period of 3 months. Patients were nebulized with 2 mL of heparin 5,000 units/mL IV formulation diluted with 3 mL of 0.9% sodium chloride, every 6 hours for a total duration of 7 days. Improvement in oxygenation (ratio of partial pressure of oxygen in blood and fraction of inspired oxygen delivered, pO2/FiO2 ratio) was calculated as the primary outcome. Other parameters like effect on inflammatory markers (neutrophil-lymphocyte ratio, total leukocyte count, interleukin (IL-6), and D-dimer values), time to liberate from mechanical ventilation, and hospital stay were calculated as secondary outcomes. In our study population, the mean age was 54.5 years and the majority of patients were males (79.0%). All patients received prone ventilation and none of them required tracheostomy. However, 5 patients (16.6%) succumbed to illness. After nebulization with unfractionated heparin, no statistically significant difference was seen in the neutrophil-lymphocyte ratio (mean = 6.87, p = 0.318) and interleukin (IL-6) levels (mean = 62.85, p = 0.6) over 7 days. Similarly, the D-dimer level also had no statistically significant change (mean = 1853.73 p = 0.570). However, there was a statistically significant improvement in oxygenation (pO2/FiO2 ratio) over 7 days (mean = 184.96, p = 0.00). Similarly, there was a significant improvement in PaO2 (84.17 ± 33.82) and SO2 (92.30 ± 3.49). Although, no significant changes were seen in the partial pressure of carbon dioxide on nebulized heparin administration. Administration of nebulized heparin in COVID-19 pneumonia with mild ARDS may improve oxygenation and result in the improvement of inflammatory markers with variable sensitivity and specificity. Gupta B, Chandrakar S, Gupta N, Jain G. Nebulized Heparin to Reduce COVID-19-induced Acute Lung Injury: A Prospective Observational Study. Indian J Crit Care Med 2023;27(3): 222-224.

Methylprednisolone pulse therapy for critically ill patients with COVID-19: a cohort study.

The guidelines recommend the use of dexamethasone 6 mg or an equivalent dose in patients with coronavirus disease 2019 (COVID-19) who require supplemental oxygen. Given that the severity of COVID-19 varies, we investigated the effect of a pulse dose of corticosteroids on the clinical course of critically ill patients with COVID-19. This single-center, retrospective cohort study was conducted between September and December 2021, which was when the Delta variant of the COVID-19 virus was predominant. We evaluated the mortality and oxygenation of severe to critical COVID-19 cases between groups that received dexamethasone 6 mg for 10 days (control group) and methylprednisolone 250 mg/day for 3 days (pulse group). Among 44 patients, 14 and 30 patients were treated with control steroids and pulse steroids, respectively. There was no difference in disease severity, time from COVID-19 diagnosis to steroid administration, or use of remdesivir or antibacterial agents between the two groups. The pulse steroid group showed a significant improvement in oxygenation before and after steroid treatment (P<0.001) compared with the control steroid group (P=0.196). There was no difference in in-hospital mortality (P=0.186); however, the pulse steroid group had a lower mortality rate (23.3%) than the control steroid group (42.9%). There was a significant difference in the length of hospital stay between both two groups (P=0.039). Pulse steroids showed no mortality benefit but were associated with oxygenation improvement and shorter hospital stay than control steroids. Hyperglycemia should be carefully monitored with pulse steroids.

798: COMPARING OUTCOMES IN RESPONDERS VERSUS NONRESPONDERS TO INHALED EPOPROSTENOL IN COVID-19 ARDS

Introduction: Novel coronavirus SARS-COV-2 is primarily spread via droplets with respiratory involvement being the most common presentation. Approximately 14% of patients with COVID-19 pneumonia will progress to develop ARDS which is associated with high mortality. Pulmonary vasodilators have been shown to improve oxygenation in severe ARDS. Inhaled epoprostenol (iEPO) promote pulmonary vasodilation by decreasing intracellular calcium and possess anti-inflammatory and antiplatelet effects which may be beneficial in C-ARDS. Methods: This was a retrospective cohort study that was IRB approved and included patients diagnosed with COVID-19 ARDS who received inhaled epoprostenol during period of 3/1/2020 and 12/31/2021. Patients that met study inclusion criteria were classified as responders or non-responders based on percent change of 10% or more in PaO2/FiO2 (PF) ratio post iEPO. The primary outcome was to compare the incidence of in-hospital mortality between both groups. Secondary outcomes included mechanical ventilation duration, ICU and hospital length of stay (LOS) and adverse events. Results: 148 patients were included in the analysis and based on post iEPO arterial blood gas (ABG) were classified as responders (n=87) and non-responders (n=61). Baseline characteristics were similar between both groups except for a lower weight and more prone positioning utilized in the responder group. Post iEPO PF ratio was significantly higher in the responder group compared to non-responder (158.69 vs. 107.67, p< 0.001) with similar duration of therapy in both groups (5.44 vs. 6.04 days, p=0.51). There was no difference in in-hospital mortality between responders and non-responders (69% vs. 72.1% p=0.68). There was no difference noted in ICU LOS, hospital LOS and duration of mechanical ventilation between both groups. A multivariable regression analysis was performed and noted no association between variables evaluated and response to inhaled epoprostenol therapy. Conclusions: Despite over 50% of patients in cohort responding to iEPO as demonstrated by significant improvement in oxygenation there was no difference in patient outcomes noted in responders as compared to non-responders.

Prone Positioning During Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome-Better Together?

Prone Positioning During Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome-Better Together?

Effect of Lateral Positioning on Oxygen Levels in an Obese, Critically Hypoxic COVID-19 Patient

COVID-19 is an infectious disease caused by SARS-CoV-2 virus. COVID-19 patients can develop a severe disease that can lead to hypoxic respiratory failure and acute respiratory distress syndrome (ARDS), which requires mechanical ventilation, prone ventilation, and salvage therapy like extracorporeal membrane oxygenation. The COVID lung is a hypoxic lung with myriad of reasons of hypoxia including poor ventilation perfusion mismatch and atelectasis. We present a case report of a morbidly obese individual managed with lateral positioning as a salvage for deteriorating PaO2/FiO2 ratio. We also demonstrated that the improvement of oxygenation was due to the recruitment of previously nonventilated lung areas as demonstrated by electrical impedance tomography (EIT). Our patient was morbidly obese and there was a dearth of man power to perform the prone position on this patient. Moreover, the sheer weight of this patient prevented us from trying the prone position. Hence, this patient was placed in a cycle of left lateral, right lateral, and supine position for 120 minutes each for the subsequent 24 hours. Significant improvement in oxygenation and ventilation was noticed in the EIT and SpO2 measurements. The EIT reading indicated ventilation redistribution to previously collapsed areas of the lung and this change persisted even when the patient was turned supine due the application of positive end expiratory pressure (PEEP) to maintain positive expiratory transpulmonary pressure. These results provide evidence of effectiveness of a lateral positioning in the improvement of oxygenation in COVID-19 ARDS.

Efficacy and feasibility of awake proning in patients with COVID-19-related acute hypoxemic respiratory failure: an observational, prospective study.

IntroductionMost of COVID-19 patients present with hypoxemic respiratory failure. Proning is one of the management options proven to improve oxygenation and reduce mortality in non-COVID-19-related acute respiratory distress syndrome. As a response to COVID-19 pandemic surge, a dedicated COVID-19 respiratory ward for the management of mild to moderate ARDS patients who require oxygen therapy, non-invasive ventilation (NIV), or high-flow nasal cannula (HFNC) was established. We adopted a policy of early awake proning in such patients.AimsTo determine the physiological changes, improvement in oxygenation, the need for intubation, alongside with the duration, tolerance, and adverse effects of awake proning. Study design and methodsSingle-center, prospective observational cohort study. All awake, non-intubated, spontaneously breathing patients with COVID-19, and hypoxemic acute respiratory failure requiring oxygen supplementation, NIV, or HFResultsFifty patients were enrolled. There was a significant improvement in oxygenation when turning the patients from supine to prone position with mean PFR was 85 (SD 13.76) in supine position which increased to 124 (SD 34.08) in prone position with substantial increase in mean PFR 1-h post proning to 138 (SD 28.01) and P-value 0.0001. Prone positioning was feasible in 41 (82%) patients (mean duration 8.5 (SD 3.13) h), and 38 (76%) patients reported that it was well tolerated.ConclusionAwake proning was feasible, tolerable, and effective in improving oxygenation in patients with COVID-19-related pneumonia and acute hypoxemic respiratory failure in this prospective study.

Prone Positioning Under ECMO: A Retrospective Cohort of 34 Patients

<h3>Purpose</h3> Extracorporeal Membrane Oxygenation (ECMO) become standard therapy for refractory hypoxemia (veno-venous (VV)) and circulatory failure (veno-arterial (VA)). However, severe hypoxemia may persist in some patients under ECMO. Prone position (PP) has been shown to have a benefit on oxygenation in patients with acute respiratory distress syndrome. We performed a retrospective study to evaluate the change of oxygenation and the risks involved in positioning patients under ECMO in PP. <h3>Methods</h3> All patients who underwent PP under ECMO from August 2014 to December 2020 were included. PP was performed on two criteria: refractory hypoxemia defined by a P/F<80mmHg despite 100% FiO2 on ventilator and ECMO or persistent hypoxemia defined by a need to maintained FiO2 ≥80% on ECMO with posterior pulmonary condensations on CT scan. Ventilatory and ECMO parameters and PP-related complications were collected. <h3>Results</h3> From 556 patients under ECMO, 34 (6.1%) (median age 54 years) were included for 87 PP procedures (2.5 +/-2.4 sessions per patient). ECMO was VA for 6 patients, VV for 27 patients and VAV for one patient. 19 patients were placed in PP for refractory hypoxemia and 15 for persistent hypoxemia. Mean tidal volume was 4.5mL/kg +/-1.7, median positive end-expiratory pressure at 10 cmH20 (IQR 10-15), respiratory rate at 20/min (IQR 18-28). Mean PP session duration was 18 h +/-4.2. Median time from ECMO placement to first PP was 7 days (IQR 4-10). PP procedures resulted in a significant improvement in oxygenation, with increasing P/F_ECMO ratio from 92.6 to 133.2 on average (p<0.0001). Concomitantly the ventilator FiO2 decreased from 65% to 55% (p<0.0001).The most frequent complication was the presence of bedsores of the face and trunk (6 patients). The other complications reported were: 1 cardio respiratory arrest due to tamponade, 1 pump thrombosis, 1 displacement of limb reperfusion cannula, 1 tracheostomy decanulation. No ECMO decanulation occurred. At discharge, 9 of 34 patients with PP (26%) had died compared to 237 on 522 patients under ECMO without PP(45.4%) (p=0.033). <h3>Conclusion</h3> PP in hypoxemic patients under ECMO is effective for improving oxygenation. A beneficial effect on mortality is also suggested. In an expert center, less than 20% of patients experienced bedsores and 12% may suffer from severe complications requiring urgent treatment.