Optimizing Non-invasive Oxygenation for COVID-19 Patients Presenting to the Emergency Department with Acute Respiratory Distress: A Case Report

Abstract

Introduction: The novel coronavirus (COVID-19) pandemic has led to an increase in the number of patients presenting to the emergency department (ED) with severe hypoxia and acute respiratory distress. With limited resources and ventilators available, emergency physicians working at a hospital within the epicenter of the United States outbreak developed a stepwise, non-invasive oxygenation strategy for treating COVID-19 patients presenting with severe hypoxia and acute respiratory distress. Case Report: A 72-year-old male suspected of having the COVID-19 virus presented to the ED with shortness of breath. He was found to be severely tachypneic, febrile, with rales in all lung fields. His initial oxygen saturation registered at SpO2 (blood oxygenation saturation) 55% on room air. Emergency physicians employed a novel non-invasive oxygenation strategy using a nasal cannula, non-rebreather, and self-proning. This approach led to a reversal of the patient’s respiratroy distress and hypoxia (SpO2 88-95%) for the following 24 hours.This non-invasive intervention allowed providers time to obtain and initiate high-flow nasal cannula and discuss end-of-life wishes with the patient and his family. Conclusion: Our case highlights a stepwise, organized approach to providing non-invasive oxygenation for COVID-19 patients presenting with severe hypoxia and acute respiratory distress. This approach primarily employs resources and equipment that are readily available to healthcare providers around the world. The intent of this strategy is to provide conventional alternatives to aid in the initial airway management of confirmed or suspected COVID-19 patients.

Clinical update on COVID-19 for the emergency clinician: Airway and resuscitation

“…Another study examined a non-invasive trial (delivered in this study using facemask and ventilator with positive pressure support and defined as NIV by the study authors) as rescue therapy if CPAP failed to avoid intubation, finding slightly lower mortality rates in patients who used a stepwise approach of CPAP, BPAP, and then endotracheal intubation (20%) versus CPAP followed by endotracheal intubation (22%) (Kaplan Meier overall survival probability P < 0.01) [ 49 ]. A suggested ladder to approaching oxygen therapy may include: 1) NC up to 6 L/min 2) Venturi mask up to 50% or NRB 3) NC + NRB 4) HFNC +/− NRB 5) NIPPV 6) endotracheal intubation ( Table 2 ) [ 29 , 30 , 40 , [50] , [51] , [52] , [53] , [54] , [55] ].…”

Risk factors, thromboembolic events, and clinical course of New‐Onset Atrial Fibrillation among COVID‐19 hospitalized patients: A multicenter cross‐sectional analysis in Iran

“…The new coronavirus disease (COVID‐19) pandemic, precipitated by severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2), 1 enormously affecting worldwide communities, has resulted in exceeding 565 million afflicted individuals and over 6 million mortalities as of late July 2022 2 . The most prevalent clinical symptoms are acute respiratory distress syndrome (ARDS) and Interstitial pneumonia 3–6 .…”