With the rapid pandemic spread of the novel coronavirus (SARS-CoV2), Emergency Departments of affected countries are facing an increasing number of patients presenting with hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). Providing mechanical support and endotracheal intubation can be challenging due to a number of patients larger than usual, often exceeding available resources. Considering the lack of recommendations available, we developed a flowchart to standardize the first approach to patients presenting to the Emergency Department with hypoxemic respiratory failure due to COVID-19.

Background: When helmet continuous positive airway pressure (H-CPAP) is performed using a Venturi system, filters are frequently interposed in the respiratory circuit to reduce noise within the helmet. The effect of the interposition of these filters on delivered fresh gas flow and the resulting inspired fraction of oxygen (FiO 2 ) is currently unknown. Methods:In a bench study, two different Venturi systems (Whisperflow and Harol) were used to generate three different gas flow/FiO 2 couples (80 L/min-FiO 2 0.6; 100 L/min-FiO 2 0.5; 120 L/min-FiO 2 0.4). Different combinations of filters were applied at the flow generator input line and/or at the helmet inlet port. Two types of filters were used for this purpose: a heat and moister exchanger filter and an electrostatic filter. The setup without filters was used as Baseline. Gas flow and FiO 2 were measured for each setup.Results: Compared to Baseline, the interposition of filters reduced the gas flow between 1 and 13% (p<0.01). The application of a filter at the Venturi system or at the Helmet generated a comparable flow reduction (-3 ± 2% vs. -4 ± 2%, p=0.12), while a greater flow reduction (-7 ± 4%) was observed when filters were applied at both sites (p<0.001). An increase in FiO 2 up to 5% was observed with filters applied. A strong inverse linear relationship (p<0.001) was observed between the resulting gas flow and FiO 2 . Conclusions:The use of filters during H-CPAP reduces the flow delivered to the helmet and, consequently, modifies FiO 2 . If filters are applied, an adequate gas flow should be administered to guarantee a constant CPAP during the entire respiratory cycle and avoid CO 2 rebreathing.Moreover, it might be important to measure the effective FiO 2 delivered to the patient to guarantee a precise assessment of oxygenation.

Purpose: The aim of this study was to evaluate the rate of successful peripheral cannulation between short-axis and long-axis ultrasound guided techniques. Methods: A single-center, two-arm randomized controlled, intention-to-treat, open-label study was conducted at the Emergency Department, between August and November 2020. Patients requiring a peripheral intravenous catheter insertion and identified as having a difficult intravascular access, were enrolled and followed for up to 96 h. The primary endpoint was the correct placement of the peripheral intravenous catheter. The secondary endpoints were number of venipunctures, intra-procedural pain, local complications, and positive blood return during the follow up. Results: A total of 283 patients were enrolled: 141 subjects were randomized to the short-axis and 142 to the long-axis group. Success rate was 96.45% (135/141; 95% CI, 91.92%–98.84%) in the short-axis group compared with 92.25% (132/142; 95% CI, 86.56%–96.07%) in the long-axis group ( p = 0.126). No significant differences were found in terms of intraprocedural pain and local complications. Higher rate of positive blood return at 72 h [3/17 long-axis, 14/17 short-axis ( p = 0.005)] and 96 h [1/10 long-axis, 9/10 short-axis 96 h, ( p = 0.022)] was found for the short-axis group. Conclusions: No differences were found between short-axis and long-axis techniques in terms of success rate, intraprocedural pain, and local complications. Despite this, a slightly higher success rate, a lower number of venipunctures, and a higher rate of positive blood return at 72 and 96 h together with an easier ultrasound technique could suggest a short-axis approach.

Background During COVID-19 outbreak, with the increasing number of patients presenting with acute respiratory failure, a large use of non-invasive positive pressure ventilation was done in the emergency departments and medical wards despite the lack of recommendations. This study describes the clinical characteristics of patients presenting to the hospital with acute respiratory failure due to COVID-19 related pneumonia undergoing treatment with helmet CPAP with a strict nursing evaluation and monitoring. Methods A case series study enrolling adult patients admitted to an emergency department of an Italian hospital with acute respiratory failure due to COVID-19 pneumonia from March 18 th to April 18 th , 2020, was conducted. Only patients who strictly followed a local CPAP protocol were enrolled. Results A total of 52 patients were included in this study. 38 patients (73%) were judged eligible for endotracheal intubation (ETI). Eight-teen (34.6%) were intubated. Six-teen (30.8%) patients died: 7 (38.9%) and 9 (26.5%) in the eligible and non-eligible for ETI group, respectively. The median hospital length of stay was different in ETI and non-ETI group: 26 days [IQR 16-37] vs 15 days [IQR 9-17] (p = 0.005). The median invasive mechanical ventilation time was 11 days [IQR 7-21] with an ICU length of stay of 14.5 days [IQR 10-28]. During the CPAP trial, among patients eligible for ETI variations over time for positive end-expiratory pressure (p = 0.003) and respiratory rate (p = 0.059) were found between intubated and non-intubated patients. Conclusions A short closed monitored CPAP trial could be considered for acute respiratory failure due to COVID-19 pneumonia before considering ETI. A progressive positive end-expiratory pressure titration should target patient’s respiratory rate reduction. More studies are needed to evaluate the efficacy and predictors of failure of CPAP and non-invasive positive pressure ventilation in patients with acute respiratory failure due to COVID-19 pneumonia.

The use of continuous positive airway pressure (CPAP) in COVID-19 hypoxemic respiratory failure (h-ARF) under a strict protocol has been described to be highly efficient. However, early prediction of failure is crucial to avoid delayed intubation. Lower PaCO2 values may represent a higher inspiratory effort and, therefore, may help identify patients at greatest risk of CPAP failure. Aim of this study was to observe the PaCO2 trend of COVID-19 patients with h-ARF before and after the initial treatment with helmet-CPAP. A case series study was conducted from November 2020 to March 2021. All adult patients with h-ARF secondary to COVID-19 treated with helmet-CPAP and eligible for endotracheal intubation were observed. Of a total of 54 patients, 32 (59.3%) underwent intubation. Seven (12.9%) patients died in the ETI group, and none in the non-ETI group. Median PaO2/FiO2 ratio on admission was 91mmHg [IQR 68-185] vs. 104mmHg [IQR 85-215] (p=0.137) in the ETI e non-ETI group, respectively. No differences were found either for PaCO2 values on admission (31.5mmHg [IQR 27-35] vs. 29.3mmHg [IQR 27.7-40]) and for PaCO2 variations after 120 minutes of CPAP (+2.38mmHg ± 3.65 vs. +2.73mmHg ± 3.96). Changes in PaCO2 values were observed during an initial helmet-CPAP trial, but no differences were found in those undergoing endotracheal intubation as compared to the others.

The aim of this article is to describe the importance of a multidisciplinary team dedicated to noninvasive ventilation training of the emergency department's staff. In our experience, the presence of a medical and nursing "noninvasive ventilation group" made it possible to quickly teach expertise on the management of noninvasive ventilation of COVID-19 patients among emergency department doctors and nurses. This allowed improving a standardized approach regarding the identification and ventilatory assistance of patients with SARS-CoV-2 pneumonia needing ventilatory support, the correct use of the devices, and quick identification and reduction of the complications associated with noninvasive ventilation.In this article, we would like to encourage the formation of similar working groups in all situations where this is not yet present.

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