Early versus late tracheal intubation in COVID-19 patients: a pro-con debate also considering heart-lung interactions

Cabrini, Luca; Ghislanzoni, L.; Severgnini, Paolo; Landoni, Giovanni; Redaelli, Martina Baiardo; Franchi, Federico; Romagnoli, Stefano

doi:10.23736/s0026-4725.20.05356-6

Cited by 11 publications

(8 citation statements)

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“…Considering the high mortality rate associated with development of barotrauma in COVID-19 patients, and the ongoing debate on optimal timing of intubation in these patients [19][20][21], we believe that it might be justified to avoid intubation in patients with Macklin-like radiological sign on chest CT, and prefer early support with alternative techniques including awake prone positioning and extracorporeal membrane oxygenation [22][23][24][25].…”

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confidence: 99%

Pneumothorax and barotrauma in invasively ventilated patients with COVID-19

Belletti

Landoni

Zangrillo

2021

Respiratory Medicine

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We read with great interest the article by Chopra et al. recently published on Respiratory Medicine [1].In their multicenter study, the Authors present incidence, clinical characteristics and outcome of pneumothorax in critically ill patients with coronavirus disease 2019 . They found that pneumothorax rate among invasively ventilated COVID-19 patients is 80/594 (13 %), and mortality rate for patients who developed pneumothorax is 50/80 (62 %). On the contrary, among 160 randomly selected invasively ventilated COVID-19 patients without pneumothorax, mortality was 78/ 160 (49 %).We recently published a systematic review on rate of barotrauma among invasively ventilated COVID-19 patients [2]. Our pooled analysis included data from 13 studies and 1814 patients [3][4][5][6][7][8][9][10][11][12][13][14][15] and we found that pooled estimate of pneumothorax rate was 10.7 % (95 % confidence interval [CI] = 6.7 %-14.7 %), while overall rate of barotrauma event was 16.1 % (95 % CI = 11.8 %-20.4 %). In addition, we found an overall mortality rate for COVID-19 patients who developed barotrauma of 61.6 % (95 % CI = 50.2 %-73.0 %), as compared with a mortality of 49.5 % (95 % CI = 41.1 %-58.0 %) for COVID-19 patients who did not develop barotrauma.We are pleased to read that our findings are further reinforced by another study, that confirms that pneumothorax rate among mechanically ventilated COVID-19 patients is between 10 and 15 %. Indeed, after including the study by Chopra et al. in an updated meta-analysis, the pooled pneumothorax rate is 11.1 % (95 % CI = 7.4 %-14.8 %) (Fig. 1), while the overall barotrauma rate is 15.4 % (95 % CI = 11.7 %-19 %) (Fig. 2). Furthermore, the study by Chopra et al. also confirms a mortality rate above 60 % for COVID-19 patients with barotrauma

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confidence: 99%

Pneumothorax and barotrauma in invasively ventilated patients with COVID-19

Belletti

Landoni

Zangrillo

2021

Respiratory Medicine

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“…Optimal timing of OTI in patients with COVID-19 is still debated [28][29][30], where lung involvement by CT imaging might be considered as an adjunctive factor contributing to this evaluation [7]. Further studies are needed to fully assess whether a more prominent role of semi-quantitative chest CT evaluation in guiding ventilatory treatment approach, with early OTI in patients with major lung anatomical involvement, might be associated with improved prognosis.…”

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confidence: 99%

Semiquantitative Chest CT Severity Score Predicts Failure of Noninvasive Positive-Pressure Ventilation in Patients Hospitalized for COVID-19 Pneumonia

Arcari¹,

Ciolina²,

Cacciotti³

et al. 2022

Journal of Cardiothoracic and Vascular Anesthesia

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Objective Non-invasive positive pressure ventilation (NPPV) emerged as an efficient tool for treatment of Coronavirus disease-19 (COVID-19) pneumonia. The factors influencing NPPV failure are still elusive. The aim of the study was to investigate the relationships between semiquantitative chest computed tomography (CT) scoring and NPPV failure and mortality in patients with COVID-19 Design Observational study Setting Non-intensive setting of care Participants N=112 patients consecutively admitted for COVID-19 pneumonia. Interventions Usual care including various degrees of respiratory support Measurements and Main Results The semi-quantitative CT-score was calculated at hospital admission. Subgroups were identified according to the ventilation strategy used (oxygen delivered by Venturi mask n=53; NPPV-responder n=38; NPPV-failure n=21). The study's primary endpoint was the use of NPPV. The secondary endpoints were NPPV failure and in-hospital death, respectively. CT-score progressively increased among groups (6 vs 9 vs 14, p<0.05 between all). CT-score was an independent predictor of all study endpoints (primary endpoint: 1.25 [95% CI 1.1-1.4], p=0.001; NPPV failure: 1.41 [95% CI 1.18-1.69], p<0.001; in-hospital mortality: 1.21 [95% CI 1.07-1.38], p=0.003). According to receiver operator characteristics curve analysis, CT-score was the most accurate variable for prediction of NPPV failure (area under the curve 0.862 with p<0.001; p<0.05 vs other variables). Conclusions We reported the common and effective use of NPPV in patients with COVID-19 pneumonia. In our population, a semi-quantitative chest CT analysis at hospital admission accurately identified those people poorly responding to NPPV.

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“…It’s been postulated that the increased intrapleural negative pressure and its consequent increased transpulmonary pressure may have deleterious effects on the lung, the so-called p-SILI. The increase of transpulmonary pressure may lead to further lung damage and increased permeability with interstitial thickening and further gas exchange derangement [ 12 , 99 , 104 , 105 ].…”

Section: When Non-invasive Respiratory Support Failsmentioning

confidence: 99%

SIMEU position paper on non-invasive respiratory support in COVID-19 pneumonia

Cosentini

Groff²,

Brambilla

et al. 2022

Intern Emerg Med

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The rapid worldwide spread of the Coronavirus disease (COVID-19) crisis has put health systems under pressure to a level never experienced before, putting intensive care units in a position to fail to meet an exponentially growing demand. The main clinical feature of the disease is a progressive arterial hypoxemia which rapidly leads to ARDS which makes the use of intensive care and mechanical ventilation almost inevitable. The difficulty of health systems to guarantee a corresponding supply of resources in intensive care, together with the uncertain results reported in the literature with respect to patients who undergo early conventional ventilation, make the search for alternative methods of oxygenation and ventilation and potentially preventive of the need for tracheal intubation, such as non-invasive respiratory support techniques particularly valuable. In this context, the Emergency Department, located between the area outside the hospital and hospital ward and ICU, assumes the role of a crucial junction, due to the possibility of applying these techniques at a sufficiently early stage and being able to rapidly evaluate their effectiveness. This position paper describes the indications for the use of non-invasive respiratory support techniques in respiratory failure secondary to COVID-19-related pneumonia, formulated by the Non-invasive Ventilation Faculty of the Italian Society of Emergency Medicine (SIMEU) on the base of what is available in the literature and on the authors' direct experience. Rationale, literature, tips & tricks, resources, risks and expected results, and patient interaction will be discussed for each one of the escalating non-invasive respiratory techniques: standard oxygen, HFNCO, CPAP, NIPPV, and awake self-repositioning. The final chapter describes our suggested approach to the failing patient.

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Early versus late tracheal intubation in COVID-19 patients: a pro-con debate also considering heart-lung interactions

Cited by 11 publications

References 0 publications

Pneumothorax and barotrauma in invasively ventilated patients with COVID-19

Pneumothorax and barotrauma in invasively ventilated patients with COVID-19

Semiquantitative Chest CT Severity Score Predicts Failure of Noninvasive Positive-Pressure Ventilation in Patients Hospitalized for COVID-19 Pneumonia

SIMEU position paper on non-invasive respiratory support in COVID-19 pneumonia

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