Non-intubated patients with acute respiratory failure due to COVID-19 could benefit from awake proning. Awake proning is an attractive intervention in settings with limited resources, as it comes with no additional costs. However, awake proning remains poorly used probably because of unfamiliarity and uncertainties regarding potential benefits and practical application. To summarize evidence for benefit and to develop a set of pragmatic recommendations for awake proning in patients with COVID-19 pneumonia, focusing on settings where resources are limited, international healthcare professionals from high and low- and middle-income countries (LMICs) with known expertise in awake proning were invited to contribute expert advice. A growing number of observational studies describe the effects of awake proning in patients with COVID-19 pneumonia in whom hypoxemia is refractory to simple measures of supplementary oxygen. Awake proning improves oxygenation in most patients, usually within minutes, and reduces dyspnea and work of breathing. The effects are maintained for up to 1 hour after turning back to supine, and mostly disappear after 6–12 hours. In available studies, awake proning was not associated with a reduction in the rate of intubation for invasive ventilation. Awake proning comes with little complications if properly implemented and monitored. Pragmatic recommendations including indications and contraindications were formulated and adjusted for resource-limited settings. Awake proning, an adjunctive treatment for hypoxemia refractory to supplemental oxygen, seems safe in non-intubated patients with COVID-19 acute respiratory failure. We provide pragmatic recommendations including indications and contraindications for the use of awake proning in LMICs.
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: Few data described practicalities of using mechanical insufflation-exsufflation (MI-E) for invasively ventilated ICU patients and evidence for benefit of their use is lacking.Aim and objective: To identify barriers and facilitators to use MI-E devices in invasively ventilated ICU patients, and to explore reasons for their use in various patient indications.Methods: Four focus group discussions; 3 national (Netherlands) and 1 with international representation, each with a purposeful interprofessional sample of a maximum 10 participants with experience in using MI-E in invasively ventilated ICU patients. We developed a semi-structured interview guide informed by the Theoretical Domain Framework. An observer was present in each session. Sessions were audio recorded and transcribed verbatim. Data were analysed using content analysis.Results: Barriers for MI-E use were lack of evidence and lack of expertise in MI-E, as well as lack of device availability within the ICU. Facilitators were experience with MI-E and perceived clinical improvement in patients with MI-E use. Common reasons to start using MI-E were difficult weaning, recurrent atelectasis and pneumonia. Main contraindications were, bullous emphysema, ARDS, high PEEP, hemodynamic instability, recent pneumothorax. There was substantial variability on used technical settings of MI-E in invasively ventilated patients.Conclusions: Key barriers and facilitators to MI-E were lack of evidence, available expertise and perceived clinical improvement. Variability on technical settings likely reflect lack of evidence. Future studies should focus on settings, safety and feasibility of MI-E in invasively ventilated patients before studies on effect can be conducted.
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