Thursday , March 4 2021

How to effectively combat respiratory failure in patients with COVID-19



Respiratory Therapist Helps Patient with COVID-19 in Los Angeles, USA - REUTERS / Lucy Nicholson
Respiratory Therapist Helps Patient with COVID-19 in Los Angeles, USA – REUTERS / Lucy Nicholson

The Acute respiratory failure is a major cause of death in patients with COVID-19. Non-invasive respiratory strategies (NIRS) they are widely used in these patients to save their lives. According to experts, the NIRS technique can reduce the need for invasive mechanical ventilation (IMV) in patients with acute respiratory failure, but patients who do not respond to NIRS have poor outcomes.

This lack of response could be special important in patients with COVID-19, as access to health services may be limited during a pandemic. Therefore, early identification of patients with COVID-19 who are unlikely to respond to NIRS treatment would be useful.

Previous studies in patients with other respiratory conditions reported low pH, low Glasgow Coma Scale score, and low oxygenation, and high heart rate, high respiratory rate, and high respiratory volume have been associated with NIV failure.

Mexican paramedic takes a break after a hard day working against a pandemic - REUTERS / Luis Cortes
Mexican paramedic takes a break after a hard day working against a pandemic – REUTERS / Luis Cortes

Similarly, a number of clinical variables and oxygenation variables, including the absence of clinical improvement in oxygenation or decreased respiratory rate, have been associated with HFNC failure and subsequent need for IMV. However, most of these variables had limited value in identifying patients who would require subsequent intubation. In patients with acute respiratory failure and pneumonia, the respiration rate and oxygenation index (ROX), based on oxygen saturation measured by pulse oximetry (SpO 2), inspiratory oxygen content (FiO 2), and respiration rate, may help identify the risk of intubation and intubation. NIRS.

However, it is unknown which indicators are useful in identifying patients with COVID-19 at high risk of NIRS failure. The aim of this study was to develop and validate a simple nomogram and an online calculator to predict the risk of NIRS failure in patients with COVID-19. who have acute respiratory failure. In a study conducted by professionals from Zhongda Hospital at the University of Southeast China, they developed and validated a network nomogram and calculator for early prediction of NIRS failure in patients with COVID-19.

Test to heal

NIRS technique can reduce the need for invasive mechanical ventilation (IMV) in patients with acute respiratory failure - REUTERS / Go Nakamura
NIRS technique can reduce the need for invasive mechanical ventilation (IMV) in patients with acute respiratory failure – REUTERS / Go Nakamura

Nomogram, based on age, number of comorbidities, ROX index, Glasgow coma scale and vasopressor use on day 1 of NIRS, has a discriminatory capacity of 95 in predicting NIRS failures. Patients in whom NIRS fails have a high risk of death. Therefore, early prediction of NIRS failure could help clinicians appropriately allocate critical care resources and identify high-risk patients for clinical trials.

In respiratory conditions other than COVID-19, several studies have shown that intubation after initial administration of NIV or HFNC is associated with poorer outcomes, such as increased mortality, in patients with acute respiratory failure. Predicting the outcome of NIRS is particularly important in patients with COVID-19, given the limited resources available during a pandemic.

Although Previous studies have suggested that the criteria for initiating HFNC or VIN and their outcomes may differ, they found that most independent risk factors for NIRS failure overlap in the HFNC and VIN groups within the group. In fact, 26% received HFNC and NIV at different times during the illness. They verified a previous predictive scale of NIV failure in patients other than COVID-19 (based on heart rate, acidosis, consciousness, oxygenation, and respiratory rate).

In non-COVID-19 respiratory conditions, several studies have shown that intubation after initial administration of NIV or HFNC is associated with poorer outcomes - REUTERS / Shannon Stapleton
In non-COVID-19 respiratory conditions, several studies have shown that intubation after initial administration of NIV or HFNC is associated with poorer outcomes – REUTERS / Shannon Stapleton

The study found that NIRS failed in 64% of cases in the training cohort and in 69% of cases in the external validation cohort; These values ​​are higher than the previously reported failure rates for HFNC (28–38%) and NIV (39–50%). Mortality at 28 days in the training and external validation cohorts was 54% and 63%, ranging from 16-78% previously described in patients with COVID-19 admitted to the ICU.

However, patients in whom NIRS failed had significantly higher mortality than previously reported in other respiratory conditions after VIN or HFNC failure. To make the prediction model simple and fast to use in a clinical setting, the experts focused only on risk factors that did not require laboratory parameters.

In conclusion, the nomogram and network calculator are easy to use and can predict the risk of failure in patients with COVID-19 treated with HFNC and NIV. Both can be used to identify patients with a high probability of NIRS failure. These patients could benefit from early triage and more intensive follow-up. The benefits of such a strategy, which could include early intubation, would require confirmation in randomized controlled trials.

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