High-flow Nasal Cannula Oxygenation Revisited in COVID-19

Abstract

The use of extracorporeal membrane oxygenation (ECMO) as salvage therapy in the most severe cases of acute respiratory distress syndrome (ARDS) has been associated with reduced mortality, particularly at highvolume centres. We report a case series of seven patients with coronavirus disease 2019 (COVID-19)-associated ARDS treated with ECMO. In select COVID-19 patients suffering from severe ARDS refractory to conventional therapy, ECMO might be an outcome altering therapy. Respiratory ECMO Survival Prediction (RESP) score appears to be a reliable prognostication tool in selecting COVID-19 patients most likely to benefit from ECMO. Early and frequent evaluation of critically ill COVID-19 patients for ECMO therapy could facilitate timely initiation, and ultimately, favourable outcomes. ECMO is a finite resource, and thus must be used judiciously, especially in the midst of a pandemic where all resources are stretched thin. ECMO is a well-established salvage therapy in treatment of severe refractory ARDS. Venous-venous ECMO (VV-ECMO) is a modified cardiopulmonary bypass system in which venous blood is removed from the body and circulated through an artificial membrane lung and has successfully been deployed in the treatment of patients with severe ARDS. The initiation of VV-ECMO allows for ultra-lung protective/'lung rest' ventilation in ARDS patients with poor lung compliance. During the H1N1 influenza pandemic, a meta-analysis of 266 patients with severe ARDS supported with VV-ECMO showed a survival rate of 72.5%, albeit with prolonged hospitalisations. 1 While previous reports on VV-ECMO in ARDS are encouraging, initial reports of its use in Chinese COVID-19 patients have been less promising. Of the six patients placed on ECMO in Wuhan, China, only one survived to hospital discharge. 2 In Shanghai, only four of eight patients survived to ECMO decannulation. 3 Early US data are similarly grim. A compiled study of 32 patients from nine different centres in the US showed a mortality rate of 31%, with 53% patients still on ECMO after 3 weeks. 4 However, there remains a paucity of literature on its utilisation and efficacy in the treatment of COVID-19-associated ARDS, especially among US patients. Methods Baylor-St Luke's Medical Center is a large, academic quaternary hospital with 661 beds in the Texas Medical Center, Houston, TX, US. It serves as a centre for advanced heart failure and heart transplantation, with a robust volume of mechanical circulatory support, including ECMO (approximately 100-150 per year). We present a case series of seven consecutive polymerase chain reaction-confirmed diagnoses of COVID-19 patients admitted to our centre between 29 March and 8 May 2020. Prior to the initiation of ECMO, patients were screened for major comorbidities, with an absolute age cutoff age of >65 years and predicted survival based on a RESP score of <40%.

Atypical Respiratory Distress Syndrome in Children Affected with COVID-19

“…The first guidelines discouraged the use of HFO or any other non-invasive, potentially aerosol-generating approach. However, with more experience in the management of COVID-19, clinicians realized that mortality in patients on invasive ventilation was high and that HFO could avoid intubation when used carefully [9]. The use of HFO in case of SARS-CoV2 infection complicated by an ARDS is rare in children.…”

Barotrauma en COVID-19: Asociación de neumotórax y uso de cánula nasal de alto flujo

“…La suma de estos factores, ha hecho que durante la pandemia por SARS-CoV-2 se haya transformado en una alternativa terapéutica a VMNI, con resultados clínicos controversiales, beneficiosos en algunos reportes y series de casos ( Karamouzos et al, 2020;Rali et al, 2020), mostrando posibles reducciones en la necesidad de ventilación mecánica invasiva en pacientes cursando falla respiratoria hipoxémica moderada (Agarwal et al, 2020;Geng et al, 2020), aunque la mayoría de estos con calidad de evidencia baja (Bruni et al, 2019).…”

Burns and Fatal Acute Lung Injury Ignited by a Smartphone Charger during Non-Invasive Ventilation for COVID-19

“…Physiologic benefits of HFNC include decreased deadspace ventilation, work of breathing, and carbon dioxide production as well as increased lung volume and improved airway mucociliary function [7,8]. With the near-ubiquity of oxygen therapy for patients hospitalized with COVID-19, entire facilities may be considered to be oxygen-enriched environments, particularly if oxygen delivery devices are positioned improperly.…”