Two mechanically ventilated cases of COVID-19 successfully managed with a sequential ventilation weaning protocol: Two case reports

Abstract

BACKGROUND Patients with critical coronavirus disease 2019 (COVID-19), characterized by respiratory failure requiring mechanical ventilation (MV), are at high risk of mortality. An effective and practical MV weaning protocol is needed for these fragile cases. CASE SUMMARY Here, we present two critical COVID-19 patients who presented with fever, cough and fatigue. COVID-19 diagnosis was confirmed based on blood cell counts, chest computed tomography (CT) imaging, and nuclei acid test results. To address the patients’ respiratory failure, they first received noninvasive ventilation (NIV). When their condition did not improve after 2 h of NIV, each patient was advanced to MV [tidal volume (Vt), 6 mL/kg ideal body weight (IBW); 8-10 cmH 2 O of positive end-expiratory pressure; respiratory rate, 20 breaths/min; and 40%-80% FiO 2 ] with prone positioning for 12 h/day for the first 5 d of MV. Extensive infection control measures were conducted to minimize morbidity, and pharmacotherapy consisting of an antiviral, immune-enhancer, and thrombosis prophylactic was administered in both cases. Upon resolution of lung changes evidenced by CT, the patients were sequentially weaned using a weaning screening test, spontaneous breathing test, and airbag leak test. After withdrawal of MV, the patients were transitioned through NIV and high-flow nasal cannula oxygen support. Both patients recovered well. CONCLUSION A MV protocol attentive to intubation/extubation timing, prone positioning early in MV, infection control, and sequential withdrawal of respiratory support, may be an effective regimen for patients with critical COVID-19.

Rehabilitation and COVID-19: the Cochrane Rehabilitation 2020 rapid living systematic review. Update as of August 31st, 2020

“…A detailed overview of the new evidence is provided in the supplementary Digital Material 1: Supplementary Table I (available on Cochrane Rehabilitation website: (https://tr.im/rr_dyn) 7 . Most studies (n=23) were conducted in Europe, 8 in Italy [8][9][10][11][12][13][14][15] , 4 in United Kingdom [16][17][18][19] , 3 in France [20][21][22] , 2 in Germany 23,24 , 2 in Switzerland 25,26 , 1 in Spain 27 , 1 in Portugal 28 , while 2 were performed as International European collaborations 29,30 ; Fifteen researches were performed in Asia (n=15), namely 3 in China [31][32][33] , 2 in Singapore 34,35 , 2 in Japan 36 , 2 in Turkey 37,38 , 2 in India 39,40 , 1 Iran 41 , 1 Kuwait 42 , 1 Pakistan 43 , 1 Taiwan 44 , whereas 11 in Americas , of whom 10 in United States of America (USA) [45][46][47][48][49][50][51][52][53][54] and 1 in Chile 55 . Two studies were carried out by Intercontin...…”

“…Due to the heterogeneity of published studies, a meta-analysis was not appropriate, so the results were qualitatively described. Based on the OCEBM 2011 Levels of Evidence table 58 the majority (76.5%) were level 4 (20 case report 8,16,18,19,21,23,[27][28][29][30]36,37,39,[42][43][44]47,49,51,53 , 10 case series 17,20,22,26,32,34,35,41,48,59 , and 9 historical cohort [9][10][11]13,15,24,[55][56][57] ), whereas the remainder 12 papers (23.5%) were of level 3 (6 cohort 12,25,33,40,46,50 and 6 cross sectional studies) 14,31,38,45,…”

“…According to the research question, the majority of studies (43.1%) investigated disease natural history/determining factors (1 cohort study 40 , 2 cross-sectional 52,54 , and 19 descriptive studies [8][9][10]19,20,27,29,30,32,[34][35][36]41,44,48,49,51,57,59 );14 descriptive papers reported epidemiological data on the clinical presentation of COVID-19 infection [16][17][18][21][22][23]26,28,37,39,42,43,47,53 , and 8 described disease prevalence (cohort study 46 , cross sectional 14,31,38,45 , historical cohort 15,24,56 ). Finally, 5 papers described data on health service organization (2 cohort studies 12,50 and 3 historical cohort COPYRIGHT© EDIZIONI MINERVA MEDICA studies 11, 13,…”

“…Thirty-two studies (62.7%) included COVID-19 patients who were assessed in the acute (20 studies) [16][17][18][19][21][22][23]26,28,32,33,[35][36][37]39,42,44,47,48,57 or post-acute phases (12 studies) 8,9,11,20,25,27,29,34,51,52,54,59 ; no studies described patients in the chronic phase. Seven studies (13.7%) reported data on the impact of COVID-19 infection on subjects with pre-existing health conditions, i.e.…”

“…Eighteen papers (35.3%) provided data about the type of rehabilitation service: 6 acute care 19,32,33,35,36,48 , 4 general post-acute 8,11,31,59 , and 8 specialized post-acute rehabilitation 10,12,25,34,51,55 including outpatients 13,50 .…”