BACKGROUND: The SpO2/FiO2 is a useful oxygenation parameter with prognostic capacity in patients with ARDS. We investigated the prognostic capacity of SpO2/FiO2 for mortality in patients with ARDS due to COVID-19.METHODS: This was a post-hoc analysis of a national multicenter cohort study in invasively ventilated patients with ARDS due to COVID-19. The primary endpoint was 28-day mortality.RESULTS: In 869 invasively ventilated patients, 28-day mortality was 30.1%. The SpO2/FiO2 on day 1 had no prognostic value. The SpO2/FiO2 on day 2 and day 3 had prognostic capacity for death, with the best cut-offs being 179 and 199, respectively. Both SpO2/FiO2 on day 2 (OR, 0.66 [95%-CI 0.46-0.96]) and on day 3 (OR, 0.70 [95%-CI 0.51-0.96]) were associated with 28-day mortality in a model corrected for age, pH, lactate levels and kidney dysfunction (AUROC 0.78 [0.76-0.79]). The measured PaO2/FiO2 and the PaO2/FiO2 calculated from SpO2/FiO2 were strongly correlated (Spearman's r = 0.79).CONCLUSIONS: In this cohort of patients with ARDS due to COVID-19, the SpO2/FiO2 on day 2 and day 3 are independently associated with and have prognostic capacity for 28-day mortality. The SpO2/FiO2 is a useful metric for risk stratification in invasively ventilated COVID-19 patients.
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Introduction: Awake proning may result in lower intubation and mortality rates in COVID-19 patients with hypoxemia refractory to simple oxygen therapy. Aims. To summarize available evidence for benefit and develop a set of pragmaticrecommendations for awake proning in COVID-19 patients.Methods. An international group of 43 healthcare professionals searched MEDLINE for articles on awake proning, and formulated recommendations for its use.Results. The professionals reached consensus regarding indications and contraindications, feasibility and safety; they recommended applying awake proning if SpO2/FiO2 < 315, or SpO2 < 93% under supplementary oxygen, and if patient is able to follow instructions. Severe hypoxemia (SpO2/FiO2 < 140) and hemodynamic instability are absolute contraindications in the ward, but relative contraindications in the ICU. Morbid obesity was also seen as a relative contraindication, depending on assistance needed to help turn the patient. Pregnancy was not seen as a contraindication, but extra monitoring in the last trimester was seen as mandatory, and extra pillows for stabilization and prevention of aortocaval compression are necessary. Five steps may improve safety: i. adequate patient information; ii. help in positioning; iii. ensuring oxygen supply and placing of tubing free at sight; iv. optimized position to prevent harm; and v. monitor oxygen saturation and respiratory rate. Dissensus remained regarding duration, and number of sessions per day, and use of sedation during prone positioning.Conclusion. Awake proning is an attractive, simple and safe way to improve oxygenation in hypoxemic COVID–19 patients. Studies remain needed to see if it effects intubation and mortality rates.
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Background: INTELLiVENT-adaptive support ventilation (ASV) is an automated closed-loop mode of invasive ventilation for use in critically ill patients. INTELLiVENT-ASV automatically adjusts, without the intervention of the caregiver, ventilator settings to achieve the lowest work and force of breathing. Aims: The aim of this case series is to describe the specific adjustments of INTELLiVENT-ASV in patients with acute hypoxemic respiratory failure, who were intubated for invasive ventilation. Study design: We describe three patients with severe acute respiratory distress syndrome (ARDS) because of COVID-19 who received invasive ventilation in our intensive care unit (ICU) in the first year of the COVID-19 pandemic. Results: INTELLiVENT-ASV could be used successfully, but only after certain adjustments in the settings of the ventilator. Specifically, the high oxygen targets that are automatically chosen by INTELLiVENT-ASV when the lung condition ‘ARDS’ is ticked had to be lowered, and the titration ranges for positive end expiratory pressure (PEEP) and inspired oxygen fraction (FiO2) had to be narrowed. Conclusions: The challenges taught us how to adjust the ventilator settings so that INTELLiVENT-ASV could be used in successive COVID-19 ARDS patients, and we experienced the benefits of this closed-loop ventilation in clinical practice. Relevance to clinical practice: INTELLiVENT-ASV is attractive to use in clinical practice. It is safe and effective in providing lung-protective ventilation. A closely observing user always remains needed. INTELLiVENT-ASV has a strong potential to reduce the workload associated with ventilation because of the automated adjustments.
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