Ventilating COVID Patients external materials (esicm, Emcrit)

COVID19 Awake Proning Ding Study

Ding, L., Wang, L., Ma, W. et al. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Crit Care 24, 28 (2020). https://doi.org/10.1186/s13054-020-2738-5

Ding et al study summarized below

Prospective observational cohort study

• Included Non-intubated moderate to severe ARDS patients were included and were placed in PP (prone position) with NIV or with HFNC.

• primary outcome was the rate of intubation.

• Severe ARDS patients were not appropriate candidates for HFNC/NIV+PP.

• Inclusion/Exclusion

• ARDS patients admitted to the respiratory ICU were evaluated with arterial blood gas analysis after a PEEP of 5 cmH2O supported by NIV (CPAP/BiPAP mode) with FiO2 0.5 for at least 30 min. ARDS patients were included if their PaO2/FiO2 was less than 200 mmHg on this level of support.

• Exclusion criteria were (1) signs of respiratory fatigue (RR > 40/min, PaCO2 > 50 mmHg/pH < 7.30, and obvious accessory respiratory muscle use), (2) immediate need for intubation (PaO2/FiO2 < 50 mmHg, unable to protect airway or change of mental status), (3) unstable hemodynamic status, and (4) inability to collaborate with PP with agitation or refusal.

• Indications for PP: Included patients were all switched to HFNC after initial evaluation by NIV. The target SpO2 was > 90% with a FiO2 equal to or lower than 0.6. Patients were placed in PP in two conditions with HFNC: (1) if the patients had a stable SpO2, they were repositioned to PP 1 h after the HFNC was initiated; (2) if patient’s SpO2 was consistently < 90% on HFNC for more than 10 min, they were put in the prone position with the same setting of HFNC. If the patients had a consistent SpO2 < 90% when on NIV evaluation with a FiO2 of 0.6, they were put in a prone position with the same setting of NIV

• Included patients were all switched to HFNC after initial evaluation by NIV. The target SpO2 was > 90% with a FiO2 equal to or lower than 0.6. Patients were placed in PP in two conditions with HFNC: (1) if the patients had a stable SpO2, they were repositioned to PP 1 h after the HFNC was initiated; (2) if patient’s SpO2 was consistently < 90% on HFNC for more than 10 min, they were put in the prone position with the same setting of HFNC. If the patients had a consistent SpO2 < 90% when on NIV evaluation with a FiO2 of 0.6, they were put in a prone position with the same setting of NIV.

• Duration and frequency of PP: patients remained in PP with HFNC or NIV for at least 30 min; if patients tolerated PP well, PP would last until the patients felt too tired to maintain that position. The PP was performed at least two times a day for the first 3 days after the patient inclusion. No sedation was used during the PP. The patients were monitored by bedside respiratory therapists and nurses for their comfort and tolerance for the PP every 15 min.

Piedmont’s Ventilator Guides

Medications (RSI and vent sedation)

Using NIPPV For Invasive Ventilation

Anesthesia vents

We are preparing for the use of Anesthesia vents as ventilator scarcity becomes more of a reality. Anesthesia will play an active role in utilizing these but here are a few references in case you need more information on how to use them.