Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2020 Sep 6;46(2):65-71.
doi: 10.1016/j.medin.2020.08.008. Online ahead of print.

Awake pronation with helmet continuous positive airway pressure for COVID-19 acute respiratory distress syndrome patients outside the ICU: A case series

[Article in English, Spanish]
G Paternoster  1 , C Sartini  2 , E Pennacchio  3 , F Lisanti  3 , G Landoni  4 , L Cabrini  5
Affiliations

Awake pronation with helmet continuous positive airway pressure for COVID-19 acute respiratory distress syndrome patients outside the ICU: A case series

[Article in English, Spanish]
G Paternoster et al. Med Intensiva (Engl Ed). .

Abstract
in English, Spanish

Objective: Continuous positive airway pressure (CPAP) is an important therapeutic tool in COVID-19 acute respiratory distress syndrome (ARDS) since it improves oxygenation, reduces respiratory rate and can prevent intubation and intensive care unit (ICU) admission. CPAP during pronation has seldom been described and never during sedation.

Design: Case series.

Setting: High dependency unit of San Carlo University Hospital (Potenza, Italy).

Patients: Eleven consecutive patients with COVID-19 ARDS.

Intervention: Helmet CPAP in prone position after failing a CPAP trial in the supine position.

Main variable of interest: Data collection at baseline and then after 24, 48 and 72h of pronation. We measured PaO2/FIO2, pH, lactate, PaCO2, SpO2, respiratory rate and the status of the patients at 28-day follow up.

Results: Patients were treated with helmet CPAP for a mean±SD of 7±2.7 days. Prone positioning was feasible in all patients, but in 7 of them dexmedetomidine improved comfort. PaO2/FIO2 improved from 107.5±20.8 before starting pronation to 244.4±106.2 after 72h (p<.001). We also observed a significantly increase in Sp02 from 90.6±2.3 to 96±3.1 (p<.001) and a decrease in respiratory rate from 27.6±4.3 to 20.1±4.7 (p=.004). No difference was observed in PaCO2 or pH. At 28 days two patients died after ICU admission, one was discharged in the main ward after ICU admission and eight were discharged home after being successfully managed outside the ICU.

Conclusions: Helmet CPAP during pronation was feasible and safe in COVID-19 ARDS managed outside the ICU and sedation with dexmedetomidine safely improved comfort. We recorded an increase in PaO2/FIO2, SpO2 and a reduction in respiratory rate.

Objetivo: La ventilación con presión positiva continua (CPAP) es una opción terapéutica útil en pacientes con síndrome de dificultad respiratoria aguda (SDRA) secundaria a infección por coronavirus 2019 (COVID-19) porque mejora la oxigenación, disminuye la frecuencia respiratoria y puede prevenir la intubación orotraqueal y así la admisión en la unidad de cuidados intensivos (UCI). El uso de la CPAP en pronación se ha descrito raramente, y nunca en pacientes con sedación superficial.

Diseño: Serie de casos.

Ámbito: Unidad de cuidados intensivos del Hospital San Carlo (Potenza, Italia).

Pacientes: Once casos consecutivos de pacientes con SDRA secundario a infección por COVID-19.

Intervenciones: Casco y CPAP y en posición de prono, después de fracasar una sesión de una hora de CPAP en posición supina.

Variables de interés principales: Datos clínicos registrados antes de iniciar la primera sesión de 12 h de pronación y a las 24, 48 y 72 h. Los datos registrados fueron PaO2/FiO2, pH, lactatos, PaCO2, SpO2, frecuencia respiratoria y visita de seguimiento a los 28 días.

Resultados: Todos los pacientes fueron tratados con CPAP y casco durante una media ± DE de 7 ± 2,7. La posición de prono se realizó con éxito en los 11 pacientes, pero 7 pacientes recibieron dexmetodomidina para mejorar el confort.

El valor de PaO2/FiO2 mejoró desde 107,5 ± 20,8 antes de la pronación hasta 244,4 ± 106,2 después de 72 h (p < 0,001). Se observó un aumento significativo de la SpO2 desde un basal de 90,6 ± 2,3 hasta 96 ± 3,1 a las 72 h (p < 0,001) y una reducción de la frecuencia respiratoria desde 27,6 ± 4,3 hasta 20,1 ± 4,7 (p = 0,004). No se observaron diferencias en los valores de PaCO2 o de pH. A los 28 días dos pacientes habían fallecido, uno permanecía todavía ingresado en la planta después de la dimisión de la UCI y ocho fueron remitidos al domicilio después de ser tratados en la planta sin necesidad de ingreso en la UCI.

Conclusiones: La CPAP con casco durante la posición de prono fue segura y eficaz en pacientes con SDRA secundario a COVID-19 en la planta, y el uso de dexmetodomidina mejoró el confort. Se observó una mejora en los valores de PaO2/FiO2, de SpO2 y de la frecuencia respiratoria.

Keywords: ARDS; ARF; Acute respiratory failure; COVID-19; CPAP; Casco; Dexmedetomidina; Dexmedetomidine; Insuficiencia respiratoria aguda; NIV; Pandemia; Pandemic; Posición prona; Pronación; Pronation; Prone position; SARS-COV-2; SARS-CoV-2; SDRA; Síndrome de dificultad respiratoria aguda.

PubMed Disclaimer

Figures

Figure 1
Figure 1
Flow chart adopted for the treatment of COVID-19 acute respiratory failure. COVID-19: coronavirus disease 19, CPAP: continuous positive airway pressure, FIO2: fraction of inspired oxygen, PaO2: arterial partial pressure of oxygen.
Figure 2
Figure 2
Trend of mean parameters at four time points: before pronation, 24, 48 and 72 h after starting pronation. Values are presented as mean. FIO2: fraction of inspired oxygen, PaCO2: arterial partial pressure of carbon dioxide, PaO2: arterial partial pressure of oxygen, SpO2: peripheral oxygen saturation.
Figure 3
Figure 3
Flow chart of the 27 patients admitted for COVID-19 acute respiratory failure. CPAP: continuous positive airway pressure, FIO2: fraction of inspired oxygen, ICU: intensive care unit, MV: mechanical ventilation, PaO2: arterial partial pressure of oxygen.
See this image and copyright information in PMC

References

    1. Wang D., Hu B., Hu C., Zhu F., Liu X., Zhang J., et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020;323:1061–1069. doi: 10.1001/jama.2020.1585. - DOI - PMC - PubMed
    1. Yang X., Yu Y., Xu J., Shu H., Xia J., Liu H., et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020;8:475–481. doi: 10.1016/S2213-2600(20)30079-5. - DOI - PMC - PubMed
    1. Arulkumaran N., Brealey D., Howell D., Singer M. Use of non-invasive ventilation for patients with COVID-19: a cause for concern? Lancet Respir Med. 2020;8:e45. doi: 10.1016/S2213-2600(20)30181-8. - DOI - PMC - PubMed
    1. Radovanovic D., Rizzi M., Pini S., Saad M., Chiumello D.A., Santus P. Helmet CPAP to treat acute hypoxemic respiratory failure in patients with COVID-19: a management strategy proposal. J Clin Med. 2020;9 - PMC - PubMed
    1. Cabrini L., Landoni G., Zangrillo A. Minimise nosocomial spread of 2019-nCoV when treating acute respiratory failure. Lancet (Lond, Engl) 2020;395:685. - PMC - PubMed