We talk about evidences on respiratory support in the dyspneic and moderately/severe hypoxic suspect COVID-19 patient on the field. Clinical evidences and contamination risks in the potentially infected COV 19 patients to guide our efforts toward a good outcome when the conventional O2 therapy is not enough.
A step backward
The COVID-19 pneumonia. More than a “baby lung”
Clinical features and Imaging in early phases
Mild dyspnea
Severe hypoxia
Low P/Fratio
Respiratory failure
Lung failure
ARDS pattern
Ground glass
Crazy paving
Clinical characteristics and imaging manifestations of the 2019 novel coronavirus disease (COVID-19):A multi-center study in Wenzhou city, Zhejiang, China
The imaging pattern of multifocal peripheral ground glass or mixed opacity with predominance in the lower lung is highly suspicious of COVID-19 in the first week of disease onset.
Lung mechanics
High compliance
Low driving pressure
Reclutability
PEEP responsive
Evidences of clinical features of OneLevel (CPAP) and BiLevel (BiPAP) respiratory support in massive epidemic crisis.
Not much of that. NIV in SARS and MERS epidemic demonstrated a poor outcome over invasive mechanical ventilation and possible delay effect on tracheal intubationand mechanical ventilation.
Noninvasive ventilation in critically ill patients with the Middle East respiratory syndrome. Basem M. Alraddadi et al. Influenza Other Respi Viruses. 2019;13:382–390
The vast majority (92.4%) of patients who were managed initially with NIV re‐ quired intubation and invasive mechanical ventilation, and were more likely to require inhaled nitric oxide compared to those who were managed initially with invasive MV. ICU and hospital length of stay were similar between NIV patients and invasive MV patients. The use of NIV was not independently associated with 90‐day mortality (propensity score‐adjusted odds ratio 0.61, 95% CI [0.23, 1.60] P = 0.27).
Clinical features OneLevel respiratory support
It’s not a ventilation but a spontaneous breathing on a fixed one expiratory level pressure. No inspiratory support.
Give a tritrable PEEP in the highly reclutable and “PEEP responsive” COVID-19 lung
Clinical features BiLevel respiratory support
It’s a proper ventilation on two level pressure
Give expiratory and inspiratory support with a tritrable driving pressure
Risk benefits assessment
More risk patient level
Patient may become agitated or combative due to hypoxia
Patient PPE must be removed
Clinicians are in close proximity to the patient’s airway
Aerosol generating events are more likely
More risk device level
High flow oxygen
Aerosol generation procedure
Poor mask sealing
Continuous manipulation at the mask/strap level to optimise sealing and patients compliance
Droplet spreading. OneLevel VS BiLevel respiratory support
DSC Hui, MTV Chan, B Chow. Aerosol dispersion during various respiratory therapies: a risk assessment model of nosocomial infection to health care workers. Hong Kong Med J 2014;20(Suppl 4):S9-13
When inspiratory positive airway pressure (IPAP) increased from 10 to 18 cmH2O, the exhaled air of a low normalised concentration through the ComfortFull 2 mask increased from 0.65 to 0.85 m at a direction perpendicular to the head of the HPS along the median sagittal plane. In contrast, when an IPAP of 10 cmH2O was applied via the Image 3 mask connected to the whisper swivel exhalation port, the exhaled air dispersed to 0.95 m towards the end of the bed along the median sagittal plane, whereas a higher IPAP resulted in wider spread of a higher concentration of smoke (….) It is also important to avoid the use of higher IPAP, which could lead to wider distribution of exhaled air and substantial room contamination.
Prehospital strategy and practical tips
When high flow conventional O2 therapy is not enough to reach clinical goals in the highly risk patient, non otherwise transportable and at risk of rapidly loosing airway patencyOne level PEEP respiratory support(CPAP) is the best compromise between clinical efficacy and contamination risk.
Ventilatory inspiratory support (BiPAP) doesn’t add much from a clinical point of view and increase the risk of contamination so has to be avoided.
Practical tips when using CPAP on the field
Use a non ventilated elbow to prevent risk of dissemination
Use a filter between the mask and the patient to prevent risk of contamination
References
Wenjie Yang et al. Clinical characteristics and imaging manifestations of the 2019 novel coronavirus disease (COVID-19):A multi-center study in Wenzhou city, Zhejiang, China. Journal of Infection. 2020
Hui DS, Chow BK, NG SS, et al. Exhaled air dispersion distances during noninvasive ventilation via different Respironics face masks. Chest 2009;136:998-1005.
Randy S. Wax, MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients, Can J Anesth/J Can Anesth. https://doi.org/10.1007/s12630-020-01591-x
WHO. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. Interim guidance 13 March 2020
Xiaobo Yang, Yuan Yu. Clinical course and outcomes of critically ill patients withSARS-CoV-2 pneumonia in Wuhan, China: a single-centered,retrospective, observational study. http://www.thelancet.com/respiratory
David J Brewster , Nicholas C Chrimes. Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group.
Our goal is to inform the global EM community with timely and high yield content about what providers like YOU are seeing and doing everyday in your local ED.
این سایت را به آن دکتوران و محصلین طب که شب و روز برای رفاه نوع انسان فداکاری می کنند ، جوانی و لذایذ زندگی را بدون چشمداشت به امتیاز و نفرین و آفرین قربان خدمت به بشر می کنند و بار سنگین خدمت و اصلاح را بدوش می کشند ، اهداء می کنم This site is dedicated to all Doctors and students that aver the great responsibility of People’s well-being upon their shoulders and carry on their onerous task with utmost dedication and Devotionاولین سایت و ژورنال انتــرنتی علـــمی ،تخـصصی ، پــژوهشــی و آمــوزشــی طبـــی در افغــانســـتان
Learning everything I can from everywhere I can. This is my little blog to keep track of new things medical, paramedical and pre-hospital from a student's perspective.
Respiratory support in suspected COVID-19 patients. When conventional O2 therapy is not enough!
20 MarWe talk about evidences on respiratory support in the dyspneic and moderately/severe hypoxic suspect COVID-19 patient on the field. Clinical evidences and contamination risks in the potentially infected COV 19 patients to guide our efforts toward a good outcome when the conventional O2 therapy is not enough.
A step backward
The COVID-19 pneumonia. More than a “baby lung”
Clinical features and Imaging in early phases
Lung mechanics
Evidences of clinical features of OneLevel (CPAP) and BiLevel (BiPAP) respiratory support in massive epidemic crisis.
Not much of that. NIV in SARS and MERS epidemic demonstrated a poor outcome over invasive mechanical ventilation and possible delay effect on tracheal intubation and mechanical ventilation.
Clinical features OneLevel respiratory support
Clinical features BiLevel respiratory support
Risk benefits assessment
More risk patient level
More risk device level
Droplet spreading. OneLevel VS BiLevel respiratory support
Prehospital strategy and practical tips
When high flow conventional O2 therapy is not enough to reach clinical goals in the highly risk patient, non otherwise transportable and at risk of rapidly loosing airway patency One level PEEP respiratory support (CPAP) is the best compromise between clinical efficacy and contamination risk.
Ventilatory inspiratory support (BiPAP) doesn’t add much from a clinical point of view and increase the risk of contamination so has to be avoided.
Practical tips when using CPAP on the field
References
Condividi:
Mi piace:
Correlati