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Home O2 in COPD. Eradicating COVID-19. mRNA and beyond. COVID-19 treatment, so far. Awake proning in COVID-19. Home ventilation. Interprofessional team approach to palliative extubation.

Publish date: February 11, 2021

 

Clinical research and quality improvement

COVID-19 treatment, so far!

COVID-19 has turned rapidly into a fatal illness, causing over 1.8 million deaths worldwide so far. The pandemic has also showed us the power of adaptive trials, multi-arm trials, and the role for collaboration across the global scientific community. A few significant studies are worth mentioning.

Dr. Muhammad Hayat Syed

Dr. Muhammad Hayat Syed

Initial therapies were with hydroxychloroquine and azithromycin, but showed no clinical improvement (Cavalcanti AB. N Engl J Med. 2020;383[21]:2041). Remdesivir, now standard of care, is based on the ACTT-1 trial, a double-blind randomized controlled trial (RCT), showing improved recovery time (Beigel JH, et al. N Engl J Med. 2020;383[19]:1813). The RECOVERY trial, a large clinical trial in the United Kingdom, demonstrated a mortality benefit (rate ratio 0.83) with dexamethasone at 28 days in those with moderate to severe COVID-19 pneumonia. Lopinavir-ritonavir combination failed to show benefit in the same trial (Horby P, et al. N Engl J Med. 2020 Jul 17. doi: 10.1056/NEJMoa2021436). Baricitinib has been shown to decrease recovery time, especially in patients with high oxygen need (Kalil AC, et al. N Engl J Med. 2020 Dec 11. doi: 10.1056/NEJMoa2031994).

Possible future therapies include antiviral monoclonal antibodies, bamlanivimab (Chen P, et al. N Engl J Med. 2020; online ahead of print); early convalescent plasma (Libster R, et al. N Engl J Med. 2021 Jan 6. doi: 10.1056/NEJMoa2033700); and casirivimab-imdevimab (Baum A, et al. Science. 2020 Nov 27 doi: 10.1126/science.abe2402). Development of mRNA COVID-19 vaccines can help with primary prevention and herd immunity (Polack FP, et al. N Engl J Med. 2020;383[27]:2603; Baden LR, et al. N Engl J Med. 2020; Dec 30; doi: 10.1056/NEJMoa2035389).

We are starting to understand why COVID-19 infection is more pathogenic in some, how to predict development of severe disease, and how to best treat respiratory failure. Defeating the pandemic will require ongoing international collaboration in research, development, and resource allocation.

Muhammad Hayat Syed, MBBS

Ankita Agarwal, MD
Fellows-in-Training Members

Critical care

Awake proning in COVID-19

Prone positioning has been shown to improve pulmonary mechanics in intubated patients with acute respiratory distress syndrome (ARDS). Proposed mechanisms for these benefits include shape matching, reversing the pleural pressure gradient, homogenizing distribution of pleural pressures, reducing the impact of the heart and abdomen on the lungs, and maintaining distribution of perfusion. Application of prone positioning has also been shown to reduce mortality in severe ARDS (Guérin, et al. N Engl J Med. 2013;368(23):2159-68). With the COVID-19 pandemic, clinicians have extrapolated that nonintubated patients with severe hypoxia may benefit from awake proning in the hopes of improving oxygenation and decreasing need for intubation. But, what’s the evidence so far?

Dr. Kathryn Pendleton

Dr. Kathryn Pendleton

In small studies, awake proning has been shown to improve oxygenation (PaO2/FIO2 ratio) and work of breathing in patients with COVID-19 who were severely hypoxic and could tolerate proning receiving high flow nasal oxygen (HFNO) or noninvasive ventilation (Weatherald, et al. J Crit Care. 2021;61:63-70). However, other studies were less conclusive. In a study by Elharrar, et al (JAMA. 2020;323(22):2336-2338), oxygenation only improved in 25% of those who were proned, and this improvement was not sustained in half of patients after they were re-supined. Additionally, a recent prospective, observational study from Spain did not show benefit to awake proning in patients receiving HFNO with respect to need for intubation or risk of mortality (Ferrando, et al. Crit Care. 2020;24(1):597).
Dr. Viren Kaul

Dr. Viren Kaul

It remains unclear whether these physiologic and short-term clinical benefits will prevent the need for mechanical ventilation and/or improve long-term outcomes, including mortality. The other nuances of application of prone positioning in spontaneously breathing patients, such as the optimal duration, positioning, clinical setting, termination criteria, and adverse effects will only become clearer with time and more robust studies. Currently, more than 60 studies examining the role of prone positioning in COVID-19 were enrolling or recently completed. Hopefully, more robust trials will provide evidence about the effectiveness of this therapy in this population. Finally, head over to CHEST’s COVID-19 Resource Center to access a downloadable infographic describing the application of prone positioning.

Kathryn Pendleton, MD

Viren Kaul, MD
Steering Committee Members

Home-Based Mechanical Ventilation and Neuromuscular Disease


New horizons in home ventilation

Phasing out a particular ventilator (Philips Respironics Trilogy 100 ventilator) has everyone on a steep learning curve with the replacement (Trilogy EVO). Most features are replicated in the EVO, including volume/pressure control and pressure-supported modes, mouthpiece ventilation, active/passive circuit capability, and portability (11.5 lb). Upgrades include longer battery life (15 hours; 7.5 hours internal/7.5 hours detachable) and use in pediatric patients now greater than or equal to 2.5 kg.

Dr. Janet Hilbert

Dr. Janet Hilbert

A significant improvement in the workhorse AVAPS-AE mode is the addition of inspiratory time control on patient-initiated breaths. In AVAPS-AE (without PC-enabled), patient-initiated breaths remain flow-cycled; however, the inspiratory time control can be achieved using Timax/Timin setting for patients with neuromuscular respiratory failure and COPD (Coleman et al. Ann Am Thorac Soc. 2019;16(9):1091-98; Nicholson, et al. Ann Am Thorac Soc. 2017;14(7):1139-46).Pressure control (PC) can now be enabled in AVAPS-AE to allow fixed Ti for both patient-initiated and device-initiated breaths, advantageous in neuromuscular disease and obesity-hypoventilation syndrome(Nicholson, et al., Ann Am Thorac Soc. 2017;14(7):1139-46; Selim, et al.,Chest. 2018;153(1):251-65).

Other significant improvements include lower flow trigger sensitivity to accommodate patients with severe respiratory muscle weakness, a fast start AVAPS with rapid breath-to-breath 3 cm H20 increases for the first minute to rapidly reach target tidal volume, and breath-to-breath auto-EPAP sensing of upper airway resistance to maintain airway patency for patients with upper airway obstruction.

Internal bluetooth transmission to cloud-based monitoring (Care OrchestratorTM) expands access to patients without wi-fi or cellular service. New monitoring modules, SpO2 and EtCO2, and transcutaneous CO2 monitoring (Sentec), transmit to cloud-based monitoring (EVO EtCs2 spring 2021).

These welcome improvements allow clinicians to better match ventilator settings to the patients’ evolving physiology and provide flexibility and connectivity to optimize long-term care.

Karin Provost, DO, PhD
Steering Committee Member

Janet Hilbert, MD
NetWork Member


Online resources
EVO e-learning curriculum

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