Ventilation In COVID-19 Patients Research Articles

Addition of Mask to High-flow Nasal Oxygen: A Strategy to Improve Oxygenation in Hypoxemic Respiratory Failure Secondary to COVID-19.

High-flow nasal cannula (HFNO) reduces the need for invasive mechanical ventilation in COVID-19 patients with hypoxemic-respiratory failure. During HFNO entrainment of room air dilutes the delivered fractional inspiratory oxygen (FiO2), thereby preventing improvement in oxygenation. The placement of a mask over HFNO to improve oxygenation has provided conflicting results. We aimed to determine and compare the effect of placing various mask types over HFNO on oxygen saturation (SPO2). In this prospective physiological study 40 patients with COVID-19-associated hypoxemic respiratory failure on HFNO with O2 concentration <92% were included. The effect of placing different masks over HFNO on oxygenation, respiratory rate, heart rate, blood pressure, patient comfort, and partial pressure of carbon dioxide level (pCO2) was recorded after a prespecified time interval. We observed a significantly higher mean SPO2 and lower mean respiratory rate on using various study masks over HFNO compared to HFNO alone. On comparing various mask types, the use of N95 masks and nonrebreather (NRB) masks with O2 showed a significant increase in O2 concentration and reduction in respiratory rate compared to surgical mask (SM) and NRB without O2. The proportion of patients who achieved SPO2 of >92% was higher with the use of N95 masks (47.5%) or NRB with O2 (45%) over HFNO compared to SM (35%) and NRB without O2 (35%). No significant change was observed in heart rate, blood pressure, and CO2 level with the use of any mask over HFNO. This study demonstrates improvement in oxygenation and reduction in respiratory rate with the use of various masks over HFNO in patients of COVID-19-related hypoxemic-respiratory-failure. Significantly greater benefit was achieved with the use of N95 or NRB with O2 compared to SM or NRB without O2.

Emergency Department SpO2/FiO2 Ratios Correlate with Mechanical Ventilation and Intensive Care Unit Requirements in COVID-19 Patients.

Patients with coronavirus 2019 (COVID-19) are at high risk for respiratory dysfunction. The pulse oximetry/fraction of inspired oxygen (SpO2/FiO2) ratio is a non-invasive assessment of respiratory dysfunction substituted for the PaO2:FiO2 ratio in Sequential Organ Failure Assessment scoring. We hypothesized that emergency department (ED) SpO2/FiO2 ratios correlate with requirement for mechanical ventilation in COVID-19 patients. Our objective was to identify COVID-19 patients at greatest risk of requiring mechanical ventilation, using SpO2/FiO2 ratios. We performed a retrospective review of patients admitted with COVID-19 at two hospitals. Highest and lowest SpO2/FiO2 ratios (percent saturation/fraction of inspired O2) were calculated on admission. We performed chi-square, univariate, and multiple regression analysis to evaluate the relationship of admission SpO2/FiO2 ratios with requirement for mechanical ventilation and intensive care unit (ICU) care. A total of 539 patients (46% female; 84% White), with a mean age 67.6 ± 18.6years, met inclusion criteria. Patients who required mechanical ventilation during their hospital stay were statistically younger in age (P = 0.001), had a higher body mass index (P < .001), and there was a higher percentage of patients who were obese (P = 0.03) and morbidly obese (P < .001). Shortness of breath, cough, and fever were the most common presenting symptoms with a median temperature of 99°F. Average white blood count was higher in patients who required ventilation (P = <0.001). A highest obtained ED SpO2/FiO2 ratio of ≤300 was associated with a requirement for mechanical ventilation. A lowest obtained ED SpO2/FiO2 ratio of ≤300 was associated with a requirement for intensive care unit care. There was no statistically significant correlation between ED SpO2/FiO2 ratios >300 and mechanical ventilation or intensive care unit (ICU) requirement. The ED SpO2/FiO2 ratios correlated with mechanical ventilation and ICU requirements during hospitalization for COVID-19. These results support ED SpO2/FiO2 as a possible triage tool and predictor of hospital resource requirements for patients admitted with COVID-19. Further investigation is warranted.

Does Colchicine Prevent Progression to Artificial Ventilation in Covid-19 Positive Patients? A Study from Lahore, Pakistan

Objective: To find out the effect of colchicine in prevention of progression to artificial ventilation in Covid-19 patients including young and elderly patients. Material and Methods: Study was conducted from 1st April 2020 till 30th September 2020 in a private, tertiary care hospital of Lahore. A retrospective cohort study was conducted on conveniently selected 179 PCR or radiologically confirmed Covid-19 positive adult and elderly, male and female patients admitted in Covid ward and Intensive care Unit (ICU) using the electronic as well as paper-based record. Amongst these patients, 33 patients were given colchicine, 137 recovered and 20 progressed to invasive ventilation. Result: Total 179 patients were included int the study and 96 (53.6%) were males and 83 (46.4%) were females. 52.5% had Diabetes mellitus, 58.7% had hypertension, 27.9% had ischemic heart disease, 8.4% had renal disease, 6.7% had lung disease/smoker. The average length of stay in hospital was 6.569±6.355 days. The outcome and progression to artificial ventilation in the patients who were given colchicine as compared to those who were not given colchicine were not statistically significant with a p value of 0.053 and 0.619, respectively. Conclusion: Colchicine has not shown a significant improvement in the outcome of Covid-19 and does not help in prevention of progression to invasive ventilation irrespective of age, gender, and co-morbidities.

Effectiveness of high flow noninvasive positive pressure ventilation in Covid-19 patients with severe acute respiratory distress syndrome

Effectiveness of high flow noninvasive positive pressure ventilation in Covid-19 patients with severe acute respiratory distress syndrome

Biomarkers and sepsis severity as predictors of mechanical ventilation and mortality in COVID-19

IntroductionPatients with septic shock face an elevated risk of mortality compared to those with sepsis. Several biomarkers, including lactate dehydrogenase, albumin, and lactate/albumin (L/A), have been associated with increased mortality in COVID-19 patients. This study aims to assess the relationship between sepsis, septic shock, and mortality, as well as the need for mechanical ventilation in COVID-19 patients. Demographic, sepsis severity factors, and biomarkers are examined. MethodsA retrospective case series from June 2020 to March 2021 included 490 patients diagnosed with sepsis or septic shock secondary to SARS-CoV-2 pneumonia. Time-to-event analyses were conducted for mechanical ventilation and mortality. Statistical significance was set at p ≤ .0038. Serum lactate, albumin, lactate/albumin ratio, C-reactive protein, platelet levels, and three sepsis severity scales, (CCI, SOFA, APACHE IV) were assessed. ResultsSepsis was identified in 352 patients (71.8%), while 138 had septic shock. Patients with septic shock were more likely to require invasive ventilator support. Factors associated with a higher risk of intubation included higher APACHE IV scores, elevated serum albumin levels, and increased L/A ratio. L/A ratio and serum lactate levels demonstrated the best diagnostic accuracy for mechanical ventilation (AUC, 0.964 and 0.946, respectively), mortality (AUC, 0.926 and 0.887, respectively). DiscussionIncreased C-reactive protein, combined with increased serum lactate and a high lactate/albumin ratio, may assist clinicians in identifying COVID-19 patients at risk of mechanical ventilation and mortality upon admission. Optimal cut-off values for lactate (1.45–1.65 mmol/L) and L/A ratio (0.413) can aid in prioritizing medical care for at risk COVID-19 patients.

Successful Versus Failed Transition From Controlled Ventilation to Pressure Support Ventilation in COVID-19 Patients: A Retrospective Cohort Study.

In patients with COVID-19 respiratory failure, controlled mechanical ventilation (CMV) is often necessary during the acute phases of the disease. Weaning from CMV to pressure support ventilation (PSV) is a key objective when the patient's respiratory functions improve. Limited evidence exists regarding the factors predicting a successful transition to PSV and its impact on patient outcomes. Retrospective observational cohort study. Twenty-four Italian ICUs from February 2020 to May 2020. Mechanically ventilated ICU patients with COVID-19-induced respiratory failure. The transition period from CMV to PSV was evaluated. We defined it as "failure of assisted breathing" if the patient returned to CMV within the first 72 hours. Of 1260 ICU patients screened, 514 were included. Three hundred fifty-seven patients successfully made the transition to PSV, while 157 failed. Pao2/Fio2 ratio before the transition emerged as an independent predictor of a successful shift (odds ratio 1.00; 95% CI, 0.99-1.00; p = 0.003). Patients in the success group displayed a better trend in Pao2/Fio2, Paco2, plateau and peak pressure, and pH level. Subjects in the failure group exhibited higher ICU mortality (hazard ratio 2.08; 95% CI, 1.42-3.06; p < 0.001), an extended ICU length of stay (successful vs. failure 21 ± 14 vs. 27 ± 17 d; p < 0.001) and a longer duration of mechanical ventilation (19 ± 18 vs. 24 ± 17 d, p = 0.04). Our study emphasizes that the Pao2/Fio2 ratio was the sole independent factor associated with a failed transition from CMV to PSV. The unsuccessful transition was associated with worse outcomes.

Comparison of Invasive and Non-Invasive Mechanical Ventilation in COVID-19 Patients Followed with Respiratory Failure

Comparison of Invasive and Non-Invasive Mechanical Ventilation in COVID-19 Patients Followed with Respiratory Failure

Assessment of the ABC2-SPH risk score to predict invasive mechanical ventilation in COVID-19 patients and comparison to other scores.

Predicting the need for invasive mechanical ventilation (IMV) is important for the allocation of human and technological resources, improvement of surveillance, and use of effective therapeutic measures. This study aimed (i) to assess whether the ABC2-SPH score is able to predict the receipt of IMV in COVID-19 patients; (ii) to compare its performance with other existing scores; (iii) to perform score recalibration, and to assess whether recalibration improved prediction. Retrospective observational cohort, which included adult laboratory-confirmed COVID-19 patients admitted in 32 hospitals, from 14 Brazilian cities. This study was conducted in two stages: (i) for the assessment of the ABC2-SPH score and comparison with other available scores, patients hospitalized from July 31, 2020, to March 31, 2022, were included; (ii) for ABC2-SPH score recalibration and also comparison with other existing scores, patients admitted from January 1, 2021, to March 31, 2022, were enrolled. For both steps, the area under the receiving operator characteristic score (AUROC) was calculated for all scores, while a calibration plot was assessed only for the ABC2-SPH score. Comparisons between ABC2-SPH and the other scores followed the Delong Test recommendations. Logistic recalibration methods were used to improve results and adapt to the studied sample. Overall, 9,350 patients were included in the study, the median age was 58.5 (IQR 47.0-69.0) years old, and 45.4% were women. Of those, 33.5% were admitted to the ICU, 25.2% received IMV, and 17.8% died. The ABC2-SPH score showed a significantly greater discriminatory capacity, than the CURB-65, STSS, and SUM scores, with potentialized results when we consider only patients younger than 80 years old (AUROC 0.714 [95% CI 0.698-0.731]). Thus, after the ABC2-SPH score recalibration, we observed improvements in calibration (slope = 1.135, intercept = 0.242) and overall performance (Brier score = 0.127). The ABC2-SPHr risk score demonstrated a good performance to predict the need for mechanical ventilation in COVID-19 hospitalized patients under 80 years of age.

Response of Tocilizumab in Treating Severe to Critical COVID-19; Single-Centre Experience at a Tertiary Care Centre

Objective: To study the effectiveness of Tocilizumab in reducing mortality in severely or critically ill patients. Study Design: Quasi-experimental study Place and Duration of Study: Mayo Hospital, Lahore Pakistan, from Dec 2020 to May 2021. Methodology: The participants meeting the inclusion criteria of the study were allocated to an Experimental and a Control Arm based on age and oxygen requirements. The Experimental-Group was given Tocilizumab plus standard care, while the Control- Group received standard care only. Primary outcome was death, while secondary outcomes were the need for invasive ventilation and length of hospital stay. Results were analyzed after 28 days. Results: Among 81 patients, 60(74.1%) were males, 21(25.9%) were females. Of these, 44(54.3) received Tocilizumab plus Standard Care, while 37(45.7%) received Standard Care only. Out of 44 patients from the Tocilizumab-Group, 21(47.7%) survived, whereas, from 37 in the Standard Care-Group, 15(40.54%) survived at the end of 28 days. However, the difference in survival distributions between the two groups was not statistically significant (p=0.41). Conclusion: Tocilizumab was found to have no significant impact on improving the chances of survival and reducing the risk of Invasive Ventilation in COVID-19 patients. A wider confidence interval, however, cannot rule out the possibility of some benefit or harm. Hence, further studies are needed on this subject.

Comparable cytokine release ex-vivo by whole blood from COVID-19 patients with and without non-invasive ventilation

T cells are key players in the resolution of the infection by SARS-CoV-2. A delay in their activation can lead to severe COVID-19. The present work aimed to identify differences in cytokine release by T cells ex-vivo between COVID-19 patients in the acute phase, showing diverse disease severity. Concentrations of IFNγ, Granzyme B, IL-6, IL-10, IL-17A, IL-18, IP-10, MCP-1, and TNFα were evaluated after stimulation ex-vivo of whole blood samples with peptides from SARS-CoV-2 spike protein and a mitogen as well as without stimulation. Samples derived from hospitalized COVID-19 patients and SARS-CoV-2 vaccinated controls (CTR). Patients were classified on disease severity considering the necessity of non-invasive ventilation (NIV). Samples from patients requiring NIV revealed a similar release of cytokines compared with patients without NIV. COVID-19 patients showed higher spontaneous production of IFNγ and IP-10, lower production of MCP-1 after SARS-CoV-2 peptide stimulation and lower production of IFNγ, IL-10, IL-17A, Granzyme B, IP-10 after mitogenic stimulus compared with CTR. In conclusion, differences in T cell responses evaluated ex-vivo by a whole blood-based cytokine release assay do not appear to explain the need for non-invasive ventilation in COVID-19 patients.

Sequential Application of Oxygen Therapy via High-flow Nasal Cannula and Non-invasive Ventilation in COVID-19 Patients with Acute Respiratory Failure in the Intensive Care Unit: A Prospective, Observational Study

Sequential Application of Oxygen Therapy via High-flow Nasal Cannula and Non-invasive Ventilation in COVID-19 Patients with Acute Respiratory Failure in the Intensive Care Unit: A Prospective, Observational Study

A Comparative Study between Non-Invasive Continuous Positive Airway Pressure Ventilation and High Flow Nasal Cannula Oxygenation among COVID-19 Patients with Acute Hypoxemic Respiratory Failure

Abstract Background Both non-invasive continuous positive airway pressure ventilation (NIV CPAP) and high flow nasal cannula oxygenation (HFNC) are beneficial in patients with acute hypoxemic respiratory failure. COVID-19 is a pandemic infectious disease caused by the coronavirus with a variable clinical picture. This study compares NIV CPAP and HFNC oxygenation in maintaining adequate ventilation, oxygenation and prevention or delaying endotracheal intubation and invasive mechanical ventilation in COVID-19 patients with acute hypoxemic respiratory failure. Objective To study the effect of NIV CPAP versus HFNC oxygenation among COVID-19 patients with acute hypoxemic respiratory failure in maintaining adequate ventilation, oxygenation and prevention or delaying endotracheal intubation when conventional oxygen therapy (COT) fails to maintain adequate oxygenation. Patients and Methods Our study compares the effect of NIV CPAP versus HFNC oxygenation among COVID-19 patients with acute hypoxemic respiratory failure in maintaining adequate ventilation, oxygenation and prevention or delaying endotracheal intubation when conventional oxygen therapy (COT) fails to maintain adequate oxygenation. Results Results showed a significant improvement in most of patients whether using NIV or HFNC and delaying intubation, with superiority of NIV over HFNC specially as regard oxygenation in terms of PaO2/FiO2. As regard invasive ventilation free days NIV-CPAP use yielded a mean invasive ventilation free days of statistically significant longer duration than HFNC group. While comparison between both groups showed that there was no significant difference as regard ICU stay days or mortality rate. Conclusion We concluded that both NI-CPAP and HFNC therapy are effective measures in respiratory support and management of acute hypoxemic respiratory failure caused by COVID-19. This is proved by improvement in oxygenation and ventilation after treatment with both NI-CPAP and HFNC which is evident by increase in both peripheral oxygen saturation (SpaO2) and PaO2/FiO2 ratio with lower both respiratory rates and PaCO2. This makes them as an excellent alternative to prevent or postpone invasive mechanical ventilation as a standalone therapy and as a bridge for respiratory recovery. This is especially important in limited resources in face of worldwide outbreak.

Unmasking of Pre-Existent Hyperglycemia and its Association with Ventilation in COVID-19 Patients: Experience at a Tertiary Care Hospital

Objective: To determine the relationship between pre-existent hyperglycemia among patients with COVID-19 pneumonia requiring oxygen supplementation.&#x0D; Study Design: Cross-sectional study&#x0D; Place and Duration of Study: COVID-19 isolation wards, High Dependency Units, and Intensive Care Units of Mayo Hospital Lahore Pakistan, from Apr to May 2021.&#x0D; Methodology: Eighty-one patients with hyperglycemia but without a prior diagnosis of diabetes mellitus were selected for this study. The data was collected from COVID PCR positive patients admitted to the isolation ward and intensive care unit at Mayo Hospital, Lahore. All the patients admitted during a 2-month duration from April to May 2021.&#x0D; Results: A Total of 81 patients were included, of which 54(66.7%) were males. On the basis of HbA1c, 68(84%), 12(14.8%) and 1 (1.2%) patient(s) were diagnosed diabetic, pre-diabetic and non-diabetic respectively. Of the four patients requiring mechanical ventilation, 3(75%) were diabetic, and 1(25%) was pre-diabetic. Of patients who required non-invasive ventilation, 68(84.4%), 12(14.2%) and 1(1.3%) were diabetic, pre-diabetic and non-diabetic, respectively.&#x0D; Conclusion: There is a significant burden of undiagnosed diabetes mellitus and pre-diabetes among patients with severe COVID-19 who require oxygen supplementation or admission to high-dependency units. Therefore, all patients should undergo thorough testing to exclude underlying diabetes mellitus.

Selecting Treatment Effects Models for Domain Adaptation Using Causal Knowledge

While a large number of causal inference models for estimating individualized treatment effects (ITE) have been developed, selecting the best one poses a unique challenge, since the counterfactuals are never observed. The problem is challenged further in the unsupervised domain adaptation (UDA) setting where we have access to labeled samples in the source domain but desire selecting an ITE model that achieves good performance on a target domain where only unlabeled samples are available. Existing selection techniques for UDA are designed for predictive models and are sub-optimal for causal inference because they (1) do not account for the missing counterfactuals and (2) only examine the discriminative density ratios between the input covariates in the source and target domain and do not factor in the model’s predictions in the target domain. We leverage the invariance of causal structures across domains to introduce a novel model selection metric specifically designed for ITE models under UDA. We propose selecting models whose predictions of the effects of interventions satisfy invariant causal structures in the target domain. Experimentally, our method selects ITE models that are more robust to covariate shifts on a variety of datasets, including estimating the effect of ventilation in COVID-19 patients.

A Retrospective Analysis of Ventilatory Strategy Comparing Non-invasive Ventilation (NIV) With Invasive Ventilation in Patients Admitted With Severe COVID-19 Pneumonia.

Background The second wave of the COVID-19 pandemic in India saw a sudden upsurge of critically ill patients getting admitted to the ICU. The guidance for respiratory support wasunclearin the early phase. But later reports showed lower mortality with non-invasive ventilation (NIV) than with intubation. The aim of this study was to assess the end result of initial methods of ventilation in COVID-19 patients. Methodology Patients admitted to ICU with COVID-19 were categorized as group 1 (IPPV-intubated within 24 hrs of admission), group 2 (NIV -NIV only), group 3 (NIV+ IPPV-intubated after 24 hrs), and group 4 (NRBM - Non-Rebreathing Mask only).All causes in the hospital or 30-day mortality, length of stay in ICU, and incidence of pneumothorax were compared between groups. Logistic regression analysis was done to determine the odds of mortality. Results The overall mortality rate among patients admitted to tertiary care centers was 15% and the rate among patients in ICU was 54.07%. Patients in group 1 and group 3 had significantly high mortality rates of 90.47% and 93.75%, respectively, as compared to 51.28% in group 2 patients. The odds of mortality were high in group 3 (OR 29.57, 95% CI 4.51 and 193.52) and group 1 (OR 8.01, 95% CI 1.35 and 47.48). Conclusion In a resource-limited setting, the use of NIV is associated with higher survival in COVID-19 patients. The prognosis of patients who are intubated early or after a trial of NIV is the same with increased odds of mortality.

Biphasic cuirass ventilation in the escalation of non-invasive ventilation in COVID-19: Case report and review.

Ventilatory alternatives to prolong noninvasive ventilation in COVID-19 patients are attractive and poorly understood. New devices to deliver negative noninvasive ventilation as biphasic cuirass ventilation (BCV) have been introduced. BCV device assist in spontaneous breathing and support ventilation. We describe a case of the combination of BCV with high-flow nasal oxygenation (HFNO) in the treatment of a COVID-19 pneumonia patient that required prolonged NIV leading to face mask intolerance, ventilator dependency secondary to residual lung fibrosis and respiratory muscular weakness. BCV provides an efficient non-invasive approach in de-escalation of therapy and weaning of prolonged NIV.

The effectiveness of non-Invasive ventilation in Covid-19 patients

Background: Endotracheal intubation is avoided more often with noninvasive ventilation (NIV) in COVID-19 patients with hypoxemia. An endotracheal or tracheostomy tube is not required to use the NIV to deliver mechanical ventilation. When inflating the lungs for oxygenation, positive pressure is provided directly to the airway while negative pressure is applied externally to the abdomen and thorax to draw air into the lungs. Methods: The study was using a quasi-experimental (single-group pre- and post-test design) and sequential sampling approach. Patients hospitalised to the corona complex at LRH-MTI in Peshawar and who tested positive for COVID 19 PCR were selected for the study. Results: There were 34.8 percent of people in the study between the ages of 30 and 45, 38.5 percent between the ages of 46 and 60, and 26.2 percent between the ages of 61 and 75. Co-infections with a positive COVID-19 PCR were found in 47.8% (66) of patients. Overall, 53.6% of patients showed significant improvement after receiving NIV and were subsequently released. For 46.4% of these patients, the NIV did not work, leading to intubation or death. Co-existing diseases were present in the majority of individuals whose NIV attempts were unsuccessful.

Non-invasive ventilation in COVID-19 patients – high vs low PEEP

Non-invasive ventilation in COVID-19 patients – high vs low PEEP

The Role of Smoking on Incidence and Prognosis of Covid-19 Patients Admitted to Tishreen University Hospital

Background: In February 2020, the World Health Organization identified Covid-19 and identified SARAS-COV2as the cause of the disease. So far, the number of infected people has exceeded 633 million, while the death toll hasexceeded 6.6 million. Since the start of the pandemic, there have been conflicting reports about smoking in termsof incidence and prognosis.Objective: The aim of this study was to investigate the effect of smoking on incidence and prognosis of COVID-19patients.Patients and Methods: An Analytic Observational Cohort study was conducted in patients with a proven diagnosisof COVID-19. They are selected from Pulmonary Medicine department, Tishreen University Hospital in Lattakia-Syria between June 2020 and December 2020. Study population were divided into two groups according to thepatient’s smoking status; group I included smoker (237 cases), and group II included non-smoker (277 cases).Results: The population of 514 patients was predominantly male (66.1%), with a mean age of 61.76±14.9 years.46.1% of the patients were smoker with presence of associated chronic diseases in 341 cases (66.3%). There wereno significant differences between two groups regarding gender and comorbidities (p&gt;0.05). Patients weresignificantly older in group I than in group II (71.22±13.2 versus 60.88±15.2, p:0.001). The rate of oxygen-basedtreatment was higher in smokers compared non-smokers (84.8% versus 67.9%, p:0.03). Non-invasive mechanicalventilation was necessary in 31 patients (13.1%) in group I versus 73 patients (26.4%) in group II, p:0.04. Theduration of hospitalization was longer in non-smoker group (7.2±4.1 versus 5.7±3.9, p:0.001). Recovery rate washigher in non-smoker patients (81.2% versus 68.4%). In addition to, 75 patients (31.6%) in smoker group diedversus 52 patients (18.8%) in non-smoker group, p: 0.005.&#x0D; Conclusion: The current study demonstrated presence of favorable inverse associations of smoking with durationof hospitalization and the need to non-invasive mechanical ventilation in COVID-19 patients.

Lung ultrasound scoring system vs ROX index as a predictor for progression to the invasive mechanical ventilation in COVID-19 patients

Lung ultrasound scoring system vs ROX index as a predictor for progression to the invasive mechanical ventilation in COVID-19 patients