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Background Previous studies suggest that prone positioning (PP) can increase PaO 2 /FiO 2 and reduce mortality in moderate to severe acute respiratory distress syndrome (ARDS). The aim of our study was to determine whether the early use of PP combined with non-invasive ventilation (NIV) or high-flow nasal cannula (HFNC) can avoid the need for intubation in moderate to severe ARDS patients. Methods This prospective observational cohort study was performed in two teaching hospitals. Non-intubated moderate to severe ARDS patients were included and were placed in PP with NIV or with HFNC. The efficacy in improving oxygenation with four support methods—HFNC, HFNC+PP, NIV, NIV+PP—were evaluated by blood gas analysis. The primary outcome was the rate of intubation. Results Between January 2018 and April 2019, 20 ARDS patients were enrolled. The main causes of ARDS were pneumonia due to influenza (9 cases, 45%) and other viruses (2 cases, 10%). Ten cases were moderate ARDS and 10 cases were severe. Eleven patients avoided intubation (success group), and 9 patients were intubated (failure group). All 7 patients with a PaO 2 /FiO 2  < 100 mmHg on NIV required intubation. PaO 2 /FiO 2 in HFNC+PP were significantly higher in the success group than in the failure group (125 ± 41 mmHg vs 119 ± 19 mmHg, P  = 0.043). PaO 2 /FiO 2 demonstrated an upward trend in patients with all four support strategies: HFNC < HFNC+PP ≤ NIV < NIV+PP. The average duration for PP was 2 h twice daily. Conclusions Early application of PP with HFNC, especially in patients with moderate ARDS and baseline SpO 2  > 95%, may help avoid intubation. The PP was well tolerated, and the efficacy on PaO 2 /FiO 2 of the four support strategies was HFNC < HFNC+PP ≤ NIV < NIV+PP. Severe ARDS patients were not appropriate candidates for HFNC/NIV+PP. Trial registration ChiCTR, ChiCTR1900023564 . Registered 1 June 2019 (retrospectively registered)

The role of non-invasive respiratory support (high-flow nasal oxygen and noninvasive ventilation) in the management of acute hypoxemic respiratory failure and acute respiratory distress syndrome is debated. The oxygenation improvement coupled with lung and diaphragm protection produced by non-invasive support may help to avoid endotracheal intubation, which prevents the complications of sedation and invasive mechanical ventilation. However, spontaneous breathing in patients with lung injury carries the risk that vigorous inspiratory effort, combined or not with mechanical increases in inspiratory airway pressure, produces high transpulmonary pressure swings and local lung overstretch. This ultimately results in additional lung damage (patient self-inflicted lung injury), so that patients intubated after a trial of noninvasive support are burdened by increased mortality. Reducing inspiratory effort by high-flow nasal oxygen or delivery of sustained positive end-expiratory pressure through the helmet interface may reduce these risks. In this physiology-to-bedside review, we provide an updated overview about the role of noninvasive respiratory support strategies as early treatment of hypoxemic respiratory failure in the intensive care unit. Noninvasive strategies appear safe and effective in mild-to-moderate hypoxemia (PaO 2 /FiO 2  > 150 mmHg), while they can yield delayed intubation with increased mortality in a significant proportion of moderate-to-severe (PaO 2 /FiO 2  ≤ 150 mmHg) cases. High-flow nasal oxygen and helmet noninvasive ventilation represent the most promising techniques for first-line treatment of severe patients. However, no conclusive evidence allows to recommend a single approach over the others in case of moderate-to-severe hypoxemia. During any treatment, strict physiological monitoring remains of paramount importance to promptly detect the need for endotracheal intubation and not delay protective ventilation.

Simon Koschel,1,2,* Sarah Bettina Stanzel,1,2,* Doreen Kroppen,1,2 Marieke Duiverman,3,4 Maximilian Wollsching-Strobel,1,2 Daniel Majorski,1,2 Melanie Patricia Berger,1,2 Falk Schumacher,2,5 Johannes Fabian Holle,2,6 Wolfram Windisch,1,2 Maximilian Zimmermann1,2 1Cologne Merheim Hospital, Department of Pneumology, Kliniken der Stadt Köln gGmbH, Cologne, Germany; 2Witten/Herdecke University, Witten, Germany; 3Department of Pulmonary Diseases and Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; 4Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands; 5Department of Rheumatology, Krankenhaus Porz Am Rhein, Cologne, Germany; 6Cologne Merheim Hospital, Department of Neurology, Kliniken der Stadt Köln gGmbH, Cologne, Germany*These authors contributed equally to this workCorrespondence: Maximilian Zimmermann, Department of Pneumology, Cologne Merheim Hospital; Kliniken der Stadt Köln gGmbH, Witten/Herdecke University, Faculty of Health/School of Medicine, Ostmerheimer Strasse 200, Köln, D-51109, Germany, Tel +49221890713468, Fax +4922189073666, Email zimmermannma@kliniken-koeln.deBackground: Non-invasive ventilation (NIV) is vital for managing chronic hypercapnic respiratory failure in COPD patients, yet the impact of handling issues like mask compliance triggering hospitalisations is often underestimated.Methods: A prospective, monocentric observational study was performed in COPD patients hospitalized for acute exacerbation with established home NIV therapy. Various questionnaires (CAT, SRI, BORG) and blood gas analysis were used to determine the severity and cause of respiratory insufficiency.Results: 59 patients (mean age 66.57 years ± 9.42, mean BMI 26.99 ± 8.63) were included. 54.24% were female (n=32). The overall cohort had a mean exacerbation rate of 2.24 ± 1.48 within the last 12 months prior to admission. Patients were divided into 4 sub cohorts based on their exacerbation trigger: infection (n=25), handling problem (n=12), non-infection (n=8), and an overlap cohort with evidence of both handling problem and non-handling problem (n=14). Significant differences exist when comparing exacerbation rate (handling-issue cohort: 2.58 ± 1.68 vs infection cohort: 1.76 ± 1.13, p=0.043), total hospital stay (handling-issue cohort: 9.25 ± 5.94 days vs infection cohort: 12.96 ± 5.76 days, p=0.039). There was no significant difference in health-related quality of life measured by the SRI (Summary Score 40.6± 12.3 vs 46.8± 14.2; p=0.103).Discussion: In our study, we were able to show that handling problems are associated with frequent exacerbations, cause long hospitalisation periods and are associated with a reduced aspects of quality of life. Patient education and training should therefore play a key role in the treatment of patients.Keywords: COPD, NIV, hospital admission, handling problems, adherence, hypercapnic respiratory failure

IntroductionThe COVID-19 pandemic has seen an unprecedented number of adults receiving non-invasive respiratory support (NIRS) with such patients having a high mortality rate.MethodsAs part of better elucidating the challenges of end of life care delivery in the COVID era, we conducted an audit of our respiratory HDU ward at Whipps Cross Hospital focusing on a 19-week period between 17/09/2020–30/01/2021 and on patients who did not survive their admission. We excluded patients that were transferred to ITU.ResultsOf a total of 309 patients receiving NIRS on our ward, 84 died during that time at a mean age of 77 (95% CI 67–87) and median of 79 years. 63 patients received CPAP, 67 received HFNT and 42 were first started on HFNT and converted to CPAP. The average length of stay was 10 days (4–16). The mean day of symptoms on presentation to hospital was 11.5 days (1.7–21.3). Average duration of symptoms prior to admission to our ward was 19.7 (9.1–30.3) days.One death was unexpected and followed a cardiac arrest. The most common indicator for a patient approaching end-of-life was hypoxia on NIRS, which was documented in 36 (43%) patients, followed by terminal agitation in 27 (32%) patients. The average time between recognising end-of-life and death was 1.4 days with a median of 2 days. 72 (86%) patients were weaned off NIRS and those who continued did so due to a medical or patient decision. Despite the vast majority (82% of patients) being on syringe drivers with an opiate and benzodiazepine most patients had persistent terminal symptoms: 51 (74%) had agitation and 38 (55%) were persistently breathlessness. Interestingly, no patient opted to rest in the prone position.DiscussionThis data primarily suggests the challenging nature of managing end-of-life care for COVID patients deteriorating on NIRS due to the high symptom load and the short time there is to achieve comfort for these individuals. Clinicians need to conduct frequent comfort reviews for such patients, consider subcutaneous infusions, as well as potentially an increase in medication doses, in conjunction with specialist palliative care input, in order to achieve comfort.

BackgroundRespiratory high-dependency units (rHDU) are widely used to manage respiratory failure in coronavirus-19 (COVID-19) outside of the intensive care unit (ICU). Wave two variants of COVID-19 have been linked to increased rates of mortality and admission to ICU, however, their impact on a rHDU population, as well as the effects of new treatments, have not been previously studied.1 In this study we aimed to compare our clinical practice and rHDU outcomes between the two main UK waves of COVID-19 infection and identify factors that influenced outcomes in the second wave.MethodWe conducted a single-centre, retrospective analysis of all patients with a diagnosis of COVID-19 admitted to the rHDU of our teaching hospital for respiratory support during the first wave from 23rd March to the 4th June 2020 and the second wave in between 10th October 2020 and 31st January 2021 when our evaluation ended. Patient data including virus genotype, treatments received and patient outcomes were collected and compared between waves.ResultsIn total, 348 patients were admitted to rHDU; 71 (20.4%) during the first wave and 277 (79.6%) in the second wave. Patient characteristics are shown in table 1. Mortality and intubation rates were lower in the second wave compared with the first. Patients in the second wave were less frail and more patients in the second wave received CPAP as their primary respiratory support and were able to prone. The VOC B.1.1.7 variant did not have a significant effect on rHDU outcome.Abstract P217 Table 1A comparison of first and second wave characteristics, treatment and outcome data First wave Second wave Mean difference (95%CI ) X2 (df) P value Age (years) 69.0 (52.0, 80.0) 62.0 (52.0, 71.0) -3.4 (-7.8 to +1.1) - 0.14 Sex:- Male- Female 49 (69.0%)22 (31.0%) 180 (65.0%)97 (35.0%) - 0.4 (1) 0.52 BMI (kg/m2) 28.5 (24.9, 33.6) 29.6 (24.8, 34.9) +0.6 (-1.7 to +2.9) - 0.63 Clinical Frailty Score:- 1 to 2 (fit) 18 (25.4%) 132 (47.7%) - 15.6 (5) 0.008 CT severity score- Moderate/severe- Severe 11 (29.7%)23 (62.2%) 131 (52.2%)113 (45.0%) - 16.0 (3) 0.0012 CRP prior to rHDU admission (mg/L) 180.6 (118.0, 210.0) 124.1 (78.1, 175.6) -44.1 (-66.9 to -21.3) - 0.0002 Spike gene testing- VOC B.1.1.7 variant- Wild-type- Ambiguous --- 143 (67.1%)57 (26.8%)13 (6.1%) - - - Dexamethasone 3 (4.2%) 266 (96.0%) - 271.4 (1) <0.0001 Remdesivir 4 (5.6%) 198 (71.5%) - 100.6 (1) <0.0001 CPAP as primary respiratory support 32 (45.1%) 248 (89.5%) - 71.1 (1) <0.0001 Able to adopt semi- or full- prone position 42 (59.2%) 237 (85.6%) - 24.8 (1) <0.0001 Admission outcome (all)- Died- Discharged 36 (50.7%)35 (49.3%) 74 (26.7%)201 (72.5%) - 14.7 (1) 0.0001 rHDU outcome (‘For Intubation’)- Died- Off respiratory support- Intubated 0 (0.0%)14 (41.2%)20 (58.8%) 7 (3.3%)152 (72.4%)51 (24.3%) - 17.3 (2) 0.0002 ConclusionOur single centre experience shows that rHDU mortality and intubation rates have improved over time in spite of the emergence of new variants. Improvements in outcome are likely to be multi-factorial. Our data support the benefit of pharmacological COVID-19 therapies in a rHDU population as well as the use of CPAP and awake proning. Other potential causes for improved outcomes are lower serological and radiological COVID-19 severity in our wave two cohort as well as reduced rates of frailty.Referencehttps://medrxiv.org/content/10.1101/2021.03.11.21253364v1

Introduction and ObjectivesThe first and second waves of COVID-19 showed different mortality patterns in hospitalized patients (Iftimi S, et al, PLos One 2021; 16(3)) but it is less clear if that holds true for severe COVID-19 patients who required respiratory support. The rationale of this study is to assess mortality difference of severe COVID-19 patients from both waves who required respiratory support.MethodsA retrospective review was conducted of all patients with severe COVID-19 requiring respiratory support including CPAP/High Flow Nasal Cannula (HFNC) admitted to a respiratory support unit at a London District Hospital in first wave (March-May 2020) and second wave (November 2020-March 2021). Mortality was assessed for CPAP/HFNC and intubation groups of each wave in accordance with age and clinical frailty score (CFS) as baseline characteristics.ResultsIn wave one, 89 patients were treated with CPAP/HFNC. 53 patients (60%) were offered CPAP/HFNC alone whilst 36 (40%) patients escalated to mechanical ventilation. In CPAP/HFNC group, 35 (66%) survived (Median age: 69, Median CFS: 2), and 18 (34%) died (Median age: 69, Median CFS: 2). In intubated group, 17 (47%) survived (Median age: 61, Median CFS: 2) and 19 (52%) died (Median age: 61, Median CFS: 2). Total 37 patients died with overall mortality 41%.In wave two, 207 patients were treated with CPAP/HFNC. Of these, 150 (73%) were offered CPAP/HFNC alone whilst 57 (27%) were escalated to mechanical ventilation. In CPAP/HFNC group, 104 (69%) survived (Median age: 66, Median CFS: 2) and 46 (31%) died (Median age: 67, Median CFS: 2). In intubated group, 33 (58%) survived (Median age 62, Median CFS: 2) and 24 (42%) died (Median age: 62, Median CFS: 2). 70 patients died in total with overall mortality 34%.ConclusionOur findings suggest overall mortality improved in second wave in severe COVID-19 patients though baseline characteristics were not significantly different. This is likely to reflect lessons relating to patient care from wave one and increasing use of steroids and IL-6 inhibitors.

IntroductionRespiratory failure in COVID pneumonia is often associated with ARDS. Invasive mechanical ventilation (IMV) is associated with high mortality and prolonged hospital stay. Continuous positive airways pressure (CPAP) has emerged as a bridge to IMV or as ceiling of care in patients with high clinical frailty scale (CFS).MethodsWe retrospectively analysed data of patients admitted our respiratory support unit (RSU) between September 2020 till January 2021. Patients admitted to our RSU received CPAP, High flow nasal oxygen( HFNO) and non invasive ventilation (NIV).Results118 patients were included in the analysis. Mean age was 71 years with 61% (n = 72) comprising of male patients. 77 patients (65%) patients receiving respiratory support (RS) died. 80(67%) patients had more 2 or more co morbidities. 60%(n=71) and 20.3% (n =24) received CPAP and HFNO as predominant modality respectively. Mean CFS was 4.3 in survival group as compared to 4.7 in survival group (p 1.98).88% patients (n=67) who died were aged above 65. Average time on RS was 7.5 days and length of stay (LOS) was 12.5 days. RS compliance was higher in survival group 85%(n=35) as compared to deceased group 42%(n=32). Time on RS in survival and deceased group were comparable 7.2 days and 8.4 days respectively (p 1.98). Time from positive PCR test to start of RS was lower in survival group (2.9 days vs 2 days, p 0.18). Mean D Dimers were 1.7 in survival group as compared to deceased group 3.5 (p 0.18). Use of syringe driver was high in deceased group (66% n=51) as compared to survival group (n=2). Mean BMI was higher in survival group (33.9 vs 28.7, p 0.001).Abstract P213 Table 1 CPAP survived CPAP Deceased P value Age 62 77 0.000004* BMI 33 28.7 0.001* CFS 4.3 4.7 1.98 CRP 89 136 0.004* D Dimer 1.7 3.6 0.18 Troponin 325 125 0.19 Time to start RS (days) 2 2.9 0.10 Length of stay(days) 13.4 12.1 0.42 Days on RS (days) 8.4 7.2 1.98 *p < 0.05 = statistically significantDiscussionAge, high CFS, and poor compliance with CPAP is associated with higher mortality in COVID 19 related ARDS. Further studies are needed to assess impact of troponin and D Dimer on COVID related ARDS outcomes.

Obesity is an important risk factor for major complications, morbidity and mortality related to intubation procedures and ventilation in the intensive care unit (ICU). The fall in functional residual capacity promotes airway closure and atelectasis formation. This narrative review presents the impact of obesity on the respiratory system and the key points to optimize airway management, noninvasive and invasive mechanical ventilation in ICU patients with obesity. Non-invasive strategies should first optimize body position with reverse Trendelenburg position or sitting position. Noninvasive ventilation (NIV) is considered as the first-line therapy in patients with obesity having a postoperative acute respiratory failure. Positive pressure pre-oxygenation before the intubation procedure is the method of reference. The use of videolaryngoscopy has to be considered by adequately trained intensivists, especially in patients with several risk factors. Regarding mechanical ventilation in patients with and without acute respiratory distress syndrome (ARDS), low tidal volume (6 ml/kg of predicted body weight) and moderate to high positive end-expiratory pressure (PEEP), with careful recruitment maneuver in selected patients, are advised. Prone positioning is a therapeutic choice in severe ARDS patients with obesity. Prophylactic NIV should be considered after extubation to prevent re-intubation. If obesity increases mortality and risk of ICU admission in the overall population, the impact of obesity on ICU mortality is less clear and several confounding factors have to be taken into account regarding the “obesity ICU paradox”.

Acute respiratory failure is a common pediatric condition requiring respiratory support invasively or non‐invasively. Limited access to proper size interface in pediatrics causes a significant drawback from using non‐invasive ventilation. We report a successful use of an adult‐size nasal interface by fitting a child's oro‐nasal area to ventilate him non‐invasively. Due to the limited access to the proper pediatric‐size of non‐invasive ventilation interfaces, using an adult‐size nasal mask as an oro‐nasal pediatric interface may overcome this limitation. However, it cannot be generalizable from this report.