Helmet continuous positive airway pressure and prone positioning: A proposal for an early management of COVID-19 patients

Longhini, Federico; Bruni, Andrea; Garofalo, Eugenio; Navalesi, Paolo; Grasselli, Giacomo; Cosentini, Roberto; Foti, Giuseppe; Mattei, Alessio; Ippolito, Mariachiara; Accurso, Giuseppe; Vitale, Filippo; Cortegiani, Andrea; Gregoretti, Cesare

doi:10.1016/j.pulmoe.2020.04.014

Cited by 63 publications

(75 citation statements)

References 51 publications

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“…Therefore, continuous positive airway pressure (CPAP) through helmet in combination with prone position was firstly attempted [8]. All routine microbiological cultures (blood, urine, and surveillance for multidrug-resistant bacteria) were also collected.…”

Section: Case Presentationmentioning

confidence: 99%

Histopathological findings in a COVID-19 patient affected by ischemic gangrenous cholecystitis

et al. 2020

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Background: Since its first documentation, a novel coronavirus (SARS-CoV-2) infection has emerged worldwide, with the consequent declaration of a pandemic disease (COVID-19). Severe forms of acute respiratory failure can develop. In addition, SARS-CoV-2 may affect organs other than the lung, such as the liver, with frequent onset of late cholestasis. We here report the histological findings of a COVID-19 patient, affected by a tardive complication of acute ischemic and gangrenous cholecystitis with a perforated and relaxed gallbladder needing urgent surgery. Case presentation: A 59-year-old Caucasian male, affected by acute respiratory failure secondary to SARS-CoV-2 infection was admitted to our intensive care unit (ICU). Due to the severity of the disease, invasive mechanical ventilation was instituted and SARS-CoV-2 treatment (azithromycin 250 mg once-daily and hydroxychloroquine 200 mg trice-daily) started. Enoxaparin 8000 IU twice-daily was also administered subcutaneously. At day 8 of ICU admission, the clinical condition improved and patient was extubated. At day 32, patient revealed abdominal pain without signs of peritonism at examination, with increased inflammatory and cholestasis indexes at blood tests. At a first abdominal CT scan, perihepatic effusion and a relaxed gallbladder with dense content were detected. The surgeon decided to wait and see the evolution of clinical conditions. The day after, conditions further worsened and a laparotomic cholecystectomy was performed. A relaxed and perforated ischemic gangrenous gallbladder, with a local tissue inflammation and perihepatic fluid, was intraoperatively met. The gallbladder and a sample of omentum, adherent to the gallbladder, were also sent for histological examination. Hematoxylin-eosin-stained slides display inflammatory infiltration and endoluminal obliteration of vessels, with wall breakthrough, hemorrhagic infarction, and nerve hypertrophy of the gallbladder. The mucosa of the gallbladder appears also atrophic. Omentum vessels also appear largely thrombosed. Immunohistochemistry demonstrates an endothelial overexpression of medium-size vessels (anti-CD31), while not in micro-vessels, with a remarkable activity of macrophages (anti-CD68) and T helper lymphocytes (anti-CD4)

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Section: Case Presentationmentioning

confidence: 99%

Histopathological findings in a COVID-19 patient affected by ischemic gangrenous cholecystitis

et al. 2020

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“…[12,13] Recent reports suggest that helmet CPAP can be effective for COVID-19 treatment, [14][15][16] possibly combined with prone or lateral position. [17][18][19] In a multicenter cohort study Aliberti et al showed that helmet CPAP signi cantly increased PaO2/FiO2 from oxygen administration alone, but that treatment failure was frequent, occurring in 44% of patients who required intubation and invasive ventilation. [20] Early recognition of patients at high risk of treatment failure is crucial, both for individual treatment and resources allocation.…”

Section: Introductionmentioning

confidence: 99%

Helmet CPAP to Treat Hypoxic Pneumonia Outside the ICU: An Observational Study During the COVID-19 Outbreak

Coppadoro

Benini

Fruscio

et al. 2020

Preprint

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Background: Respiratory failure due to COVID-19 pneumonia is associated with high mortality and may threaten healthcare systems hold, due to the surge patients requiring advanced respiratory support. Shortage of intensive care unit (ICU) beds required many patients to be treated outside the ICU despite severe hypoxia. Helmet is as effective interface to provide Continuous Positive Airway Pressure (CPAP) non-invasively. We report data about the usefulness of helmet CPAP during pandemic, either as an effective treatment, a bridge to intubation or a rescue therapy for patients with care limitations (DNI).Methods: In this observational study we collected data regarding patients failing standard oxygen therapy (i.e. non-rebreathing mask) due to COVID-19 pneumonia treated with a free flow helmet CPAP system. Patients’ data were recorded before, at initiation of CPAP treatment and once a day, since. CPAP failure was defined as a composite outcome of intubation or death.Results: A total of 306 patients were included; 42% were deemed as DNI. Helmet CPAP treatment was successful in 69% of the full-treatment and 29% of the DNI patients (P<0.001). With helmet CPAP, PaO2/FiO2 ratio doubled from about 100 to 200 mmHg (P<0.001); respiratory rate decreased from 28 [22-32] to 24 [20-29] breaths per minute, P<0.001). CPAP failure was independently associated with CRP, time to oxygen mask failure, age, PaO2/FiO2 during CPAP, number of comorbidities. Helmet CPAP was maintained for 6 [3-9] days, almost continuously during the first two days. None of the full treatment patients died before intubation in the wardsConclusions: Helmet CPAP treatment is feasible for several days outside the ICU, despite persisting hypoxia. It is effective, avoiding intubation in the majority of full treatment patients when standard oxygen therapy fails. DNI patients could benefit from helmet CPAP as rescue therapy to improve survival.Trial Registration: NCT04424992

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“…Awake proning seems to be bene cial in COVID-19 and should optimally be available to both treatment groups (18). In early May, Italian researchers published data to support the rational and feasibility of combining the Helmet CPAP and prone positioning without reports of harm (19,20). Third was the number of COVID-19 patients requiring intermediate-level care in our institution.…”

Section: Discussionmentioning

confidence: 91%

Helmet Continuous Positive Airway Pressure versus High-Flow Nasal Cannula in COVID-19: A pragmatic randomised clinical trial (COVID HELMET)

Tverring

Åkesson²,

Nielsen

2020

Preprint

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Background: Patients with COVID-19 and hypoxemia despite conventional low-flow oxygen therapy are often treated with High-flow Nasal Cannula (HFNC) in line with international guidelines. Oxygen delivery by Helmet Continuous Positive Airway Pressure (CPAP) is a feasible option that enables a higher positive end-expiratory pressure (PEEP) and may theoretically reduce the need for intubation compared to HFNC but direct comparative evidence is lacking. Methods: We plan to perform an investigator-initiated, pragmatic, randomised trial at an intermediate-level COVID-19 cohort ward in Helsingborg Hospital, southern Sweden. We have estimated a required sample size of 120 patients randomised 1:1 to HFNC or Helmet CPAP to achieve 90% power to detect superiority at a 0.05 significance level regarding the primary outcome of ventilator free days (VFD) within 28 days using a Mann-Whitney U test. Patient recruitment is planned to being June 2020 and be completed in the first half of 2021. Discussion: We hypothesize that the use of Helmet CPAP will reduce the need for invasive mechanical ventilation compared to the use of HFNC without having a negative effect on survival. This could have important implications during the current COVID-19 epidemic. Trial registration: ClinicalTrials.gov, NCT04395807, Registered 20 May 2020, https://clinicaltrials.gov/ct2/show/NCT04395807

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Helmet continuous positive airway pressure and prone positioning: A proposal for an early management of COVID-19 patients

Cited by 63 publications

References 51 publications

Histopathological findings in a COVID-19 patient affected by ischemic gangrenous cholecystitis

Histopathological findings in a COVID-19 patient affected by ischemic gangrenous cholecystitis

Helmet CPAP to Treat Hypoxic Pneumonia Outside the ICU: An Observational Study During the COVID-19 Outbreak

Helmet Continuous Positive Airway Pressure versus High-Flow Nasal Cannula in COVID-19: A pragmatic randomised clinical trial (COVID HELMET)

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Helmet continuous positive airway pressure and prone positioning: A proposal for an early management of COVID-19 patients

Cited by 63 publications

References 51 publications

Histopathological findings in a COVID-19 patient affected by ischemic gangrenous cholecystitis

Histopathological findings in a COVID-19 patient affected by ischemic gangrenous cholecystitis

Helmet CPAP&nbsp;to Treat Hypoxic Pneumonia Outside the ICU: An Observational Study During the COVID-19 Outbreak

Helmet Continuous Positive Airway Pressure versus High-Flow Nasal Cannula in COVID-19: A pragmatic randomised clinical trial (COVID HELMET)

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Product

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Helmet CPAP to Treat Hypoxic Pneumonia Outside the ICU: An Observational Study During the COVID-19 Outbreak