Advanced Respiratory Monitoring in COVID-19 Patients: Use Less PEEP!

Roesthuis, Lisanne; Berg, Maarten van den; Hoeven, Hans van der

doi:10.20944/preprints202004.0275.v1

Cited by 5 publications

(7 citation statements)

References 9 publications

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“…Other authors have speculated that using high levels of PEEP in COVID-19 patients with low recruitability may be detrimental, and that lowering PEEP may improve gas exchange and limit ventilator induced lung injury [32]. Our results in this large cohort of patients from multiple global areas support this theory.…”

Section: Discussionsupporting

confidence: 80%

An Appraisal of Respiratory System Compliance In Mechanically Ventilated Covid-19 Patients

Bassi

Suen²,

Dalton

et al. 2020

Preprint

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Background Heterogeneous respiratory system static compliance (CRS) values and levels of hypoxemia in patients with novel coronavirus disease (COVID-19) requiring mechanical ventilation have been reported in previous small-case series or studies conducted at a national level. Methods We designed a retrospective observational cohort study with rapid data gathering from the international COVID-19 Critical Care Consortium study to comprehensively describe the impact of CRS on the ventilatory management and outcomes of COVID-19 patients on mechanical ventilation (MV), admitted to intensive care units (ICU) worldwide. Results We enrolled 318 COVID-19 patients enrolled into the study from January 14th through September 31th, 2020 in 19 countries and stratified into two CRS groups. CRS was calculated as: tidal volume/[airway plateau pressure-positive end-expiratory pressure (PEEP)] and available within 48 h from commencement of MV in 318 patients. Patients were mean ± SD of 58.0 ± 12.2, predominantly from Europe (54%) and males (68%). Median CRS (IQR) was 34.1 mL/cmH2O (26.5–45.5) and PaO2/FiO2 was 119 mmHg (87.1–164) and was not correlated with CRS. Female sex presented lower CRS than in males (95% CI: -13.8 to -8.5 P < 0.001) and higher body mass index (34.7 ± 10.9 vs 29.1 ± 6.0, p < 0.001). Median (IQR) PEEP was 12 cmH2O (10–15), throughout the range of CRS, while median (IQR) driving pressure was 12.3 (10–15) cmH2O and significantly decreased as CRS improved (p < 0.001). No differences were found in comorbidities and clinical management between CRS strata. In addition, 28-day ICU mortality and hospital mortality did not differ between CRS groups. Conclusions This multicentre report provides a comprehensive account of CRS in COVID-19 patients on MV – predominantly males or overweight females, in their late 50 s – admitted to ICU during the first international outbreaks. Phenotypes associated with different CRS upon commencement of MV could not be identified. Trial documentation: Available at https://www.covid-critical.com/study. Trial registration ACTRN12620000421932.

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Section: Discussionsupporting

confidence: 80%

An Appraisal of Respiratory System Compliance In Mechanically Ventilated Covid-19 Patients

Bassi

Suen²,

Dalton

et al. 2020

Preprint

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“…(29)(30)(31)(32)(33)(34), the model provides a heterogeneous disease profile distributed across 100 gas-exchanging compartments implementing (a) vasodilation leading to hyperperfusion of collapsed lung regions, (b) disruption of hypoxic pulmonary vasoconstriction, with hypoperfusion of normally aerated lung regions (c) disruption of alveolar gas-exchange due to the effects of pneumonitis, and (d) heightened vascular resistance due to the presence of microthrombi, while maintaining relatively well preserved lung compliance and gas volumes. It replicates closely the levels of ventilationperfusion mismatch and hypoxemia (34,35), as well as the lack of responsiveness to PEEP (36)(37)(38), that has been documented in some patients with COVID-19; see (28) and the supplementary file for full details.…”

Section: Methodssupporting

confidence: 73%

High risk of patient self-inflicted lung injury in COVID-19 with frequently encountered spontaneous breathing patterns: a computational modelling study

Weaver

Das

Saffaran

et al. 2021

Preprint

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There is ongoing controversy regarding the potential for increased respiratory effort to generate patient self-inflicted lung injury (P-SILI) in spontaneously breathing patients with COVID-19 acute respiratory failure. However, direct clinical evidence linking increased inspiratory effort to lung injury is scarce. We adapted a recently developed computational simulator that replicates distinctive features of COVID-19 pathophysiology to quantify the mechanical forces that could lead to P-SILI at different levels of respiratory effort. In accordance with recent data, the simulator was calibrated to represent a spontaneously breathing COVID-19 patient with severe hypoxaemia (SaO2 80.6%) and relatively well-preserved lung mechanics (lung compliance of 47.5 ml/cmH2O), being treated with supplemental oxygen (FiO2 = 100%). Simulations were conducted at tidal volumes (VT) and respiratory rates (RR) of 7 ml/kg and 14 breaths/min (representing normal respiratory effort) and at VT/RR of 15/14, 7/20, 15/20, 10/30, 12/30, 10/35, 12/35, 10/40, 12/40 ml/kg / breaths/min. Lung compliance was unaffected by increased VT but decreased significantly at higher RR. While oxygenation improved, significant increases in multiple indicators of the potential for lung injury were observed at all higher VT/RR combinations tested. Pleural pressure swing increased from 10.1 cmH2O at baseline to 30 cmH2O at VT/RR of 15 ml/kg / 20 breaths/min and to 54.6 cmH2O at 12 ml/kg / 40 breaths/min. Dynamic strain increased from 0.3 to 0.49 at VT/RR of 12 ml/kg / 30 breaths/min, and to 0.6 at 15 ml/kg / 20 breaths/min. Mechanical power increased from 7.83 J/min to 17.7 J/min at VT/RR of 7 ml/kg / 20 breaths/min, and to 240.5 7 J/min at 12 ml/kg / 40 breaths/min. Our results suggest that the forces generated during increased inspiratory effort in severe COVID-19 are compatible with the development of P-SILI. If conventional oxygen therapy or non-invasive ventilation is ineffective in reducing respiratory effort, control of driving and transpulmonary pressures with invasive ventilation may reduce the risk of P-SILI and allow time for the resolution of the underlying condition.

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“…All articles that discussed ventilation strategies recommended the use of lowtidal volume ventilation with tidal volumes anywhere between 4 and 8 mL/kg of predicted body weight (PBW) according to recommendation by the ARDS Network, derived from HICs. 45,46,[58][59][60][61][62][63][64][65][66] Among articles suggesting severe COVID-19 pneumonia phenotypes, at least one suggested using tidal volumes on the higher end of the spectrum (6-8 mL/kg PBW) to attenuate dyspnea. 58 However, this recommendation is based on small case series of low quality and on phenotypes not externally validated.…”

Section: In Hypoxemic Covid-19 Patients In Lmics We Recommendmentioning

confidence: 99%

“…Among the studies that discussed phenotypes of patients with severe COVID-19 pneumonia requiring invasive mechanical ventilation, 45,46,[58][59][60][61][62][63][64][65] a common theme was the identification of two classes of patients: patients with a preserved to near normal (> 50 mL/cmH 2 O) respiratory system compliance or those with a low respiratory systemic compliance (< 40 mL/cmH 2 O). However, no validation or ventilation strategy tailored by these phenotypes was tested.…”

Section: In Hypoxemic Covid-19 Patients In Lmics We Recommendmentioning

confidence: 99%

“…At least five studies suggested using low to moderate levels of positive end-expiratory pressure (PEEP) (8-10 cmH 2 O) for those with preserved compliance and higher levels of PEEP (> 10 cmH 2 O) among those with low compliance or a more typical presentation of ARDS. 45,[58][59][60][61][62] However, these recommendations were not validated in larger and well-performed multicenter studies or clinical trials. One study suggested overall poor alveolar recruitability in severe COVID-19 pneumonia.…”

Section: In Hypoxemic Covid-19 Patients In Lmics We Recommendmentioning

confidence: 99%

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Pragmatic Recommendations for the Management of Acute Respiratory Failure and Mechanical Ventilation in Patients with COVID-19 in Low- and Middle-Income Countries

Neto

Checkley

Sivakorn

et al. 2021

The American Journal of Tropical Medicine and Hygiene

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Management of patients with severe or critical COVID-19 is mainly modeled after care for patients with severe pneumonia or acute respiratory distress syndrome (ARDS) from other causes, and these recommendations are based on evidence that often originates from investigations in resource-rich intensive care units located in high-income countries. Often, it is impractical to apply these recommendations to resource-restricted settings, particularly in low-and middle-income countries (LMICs). We report on a set of pragmatic recommendations for acute respiratory failure and mechanical ventilation management in patients with severe/critical COVID-19 in LMICs. We suggest starting supplementary oxygen when SpO 2 is persistently lower than 94%. We recommend supplemental oxygen to keep SpO 2 at 88-95% and suggest higher targets in settings where continuous pulse oximetry is not available but intermittent pulse oximetry is. We suggest a trial of awake prone positioning in patients who remain hypoxemic; however, this requires close monitoring, and clear failure and escalation criteria. In places with an adequate number and trained staff, the strategy seems safe. We recommend to intubate based on signs of respiratory distress more than on refractory hypoxemia alone, and we recommend close monitoring for respiratory worsening and early intubation if worsening occurs. We recommend low-tidal volume ventilation combined with FiO 2 and positive end-expiratory pressure (PEEP) management based on a high FiO 2 /low PEEP table. We recommend against using routine recruitment maneuvers, unless as a rescue therapy in refractory hypoxemia, and we recommend using prone positioning for 12-16 hours in case of refractory hypoxemia (PaO 2 / FiO 2 < 150 mmHg, FiO 2 ³ 0.6 and PEEP ³ 10 cmH 2 O) in intubated patients as standard in ARDS patients. We also recommend against sharing one ventilator for multiple patients. We recommend daily assessments for readiness for weaning by a low-level pressure support and recommend against using a T-piece trial because of aerosolization risk.

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Advanced Respiratory Monitoring in COVID-19 Patients: Use Less PEEP!

Cited by 5 publications

References 9 publications

An Appraisal of Respiratory System Compliance In Mechanically Ventilated Covid-19 Patients

An Appraisal of Respiratory System Compliance In Mechanically Ventilated Covid-19 Patients

High risk of patient self-inflicted lung injury in COVID-19 with frequently encountered spontaneous breathing patterns: a computational modelling study

Pragmatic Recommendations for the Management of Acute Respiratory Failure and Mechanical Ventilation in Patients with COVID-19 in Low- and Middle-Income Countries

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