Reorganizing the respiratory high dependency unit for pandemics.
TL;DR: In this article, the authors summarized the dual purpose of Respiratory High Dependency Units (RHDUs) and proposed an adaptation and optimization of the RHDUs to meet the emergent needs caused by the pandemic emphasizing the role of the expert application of noninvasive respiratory therapies in preventing intubation and ICU access.
Abstract: Introduction : Respiratory high dependency units (RHDU) set up in European countries in the last decade are based on being a transitional step between the intensive care units (ICU) and the conventional hospital ward in terms of staffing, level of monitoring and patients' severity. In the pre-COVID-19 era, its main use has been the treatment of hypercapnic acute-on-chronic respiratory failure with noninvasive respiratory support and more recently for hypoxemic acute respiratory failure. Areas covered We searched the following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, limited to the terms: COVID-19 AND RHDU, Respiratory Intermediate care Unit, acute respiratory distress syndrome (ARDS), non invasive ventilation (NIV), high flow nasal cannula (HFNC), prone position, monitoring. In this review we summarize RHDU´s dual purpose: on one hand, to decrease the number of admissions into ICU, and on the other hand, early discharges of patients from ICU with prolonged admissions due to the need of care or laborious weaning from invasive mechanical ventilation. Although this dual purpose of RHDUs has contributed to decrease the overload of the ICUs during the pandemic, the hundreds of patients admitted in hospitals, with approximately 20% -30% needing critical care, has exceeded the forecasts of many hospitals. Expert opinion It seems clear that a reorganization and optimization of the care of patients with severe COVID-19 is necessary, minimizing admissions to the ICU and facilitating an early discharge. During the pandemic, several hospitals have spontaneously created new RHDUs or extended pre-existing RHDUs or up-graded respiratory wards in order to receive less sick patients requiring lower levels of monitoring and nurse to patient ratios. This article reviews under a European expert perspective this topic and proposes an adaptation and optimization of the RHDUs to meet the emergent needs caused by the pandemic emphasizing the role of the expert application of noninvasive respiratory therapies in preventing intubation and ICU access.
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TL;DR: In this paper , a multicenter observational study in Japan suggests that care for mechanically ventilated patients with COVID-19 in the ICU may significantly reduce in-hospital mortality within 30 days compared with care in the HDU.
Abstract: Rationale: High-dependency care units (HDUs), also termed "intermediate care units", "step-down units", or "respiratory HDUs", are areas in which degrees of patient care and costs are between those of the intensive care unit (ICU) and the general ward. In general, patients requiring mechanical ventilation are treated in the ICU rather than in the HDU, except for the use of HDU beds as surge capacity beds during a massive strain; however, the HDU, as well as ICU, are used as the standard care units for mechanically ventilated patients with coronavirus disease (COVID-19) in Japan. Objectives: To assess the outcomes of patients with COVID-19 with invasive mechanical ventilation treated in the HDU versus those treated in the ICU. Methods: In this retrospective cohort study, we used a multicenter inpatient database in Japan to identify mechanically ventilated patients with COVID-19 in the ICU or HDU on the start day of invasive mechanical ventilation from February 10, 2020, to November 30, 2021. The primary outcome was in-hospital mortality within 30 days from the start of the first invasive mechanical ventilation. Propensity score matching was performed to compare the outcomes of patients treated in the ICU with those treated in the HDU. Results: Of 1,985 eligible patients with COVID-19 with invasive mechanical ventilation, 1,303 (66%) were treated in the ICU, and 682 (34%) were treated in the HDU on the start day of invasive mechanical ventilation. After propensity score matching, patients treated in the ICU had significantly lower in-hospital mortality within 30 days than those treated in the HDU (18.3% vs. 24.2%; risk difference, -5.8%; 95% confidence interval, -10.9% to -0.8%). Conclusions: This multicenter observational study in Japan suggests that care for mechanically ventilated patients with COVID-19 in the ICU may significantly reduce in-hospital mortality within 30 days compared with care in the HDU. Establishing a critical care system that would allow patients with COVID-19 requiring ventilators to be treated in the ICU is desirable. Because this study was an observational study, our finding represents an association, not causation. Further studies of different critical care systems are warranted to confirm our findings.
5 citations
19 Aug 2022
TL;DR: This multicenter observational study in Japan suggests that care for mechanically ventilated COVID-19 patients in the ICU may significantly reduce in-hospital mortality within 30 days compared with care in the HDU.
Abstract: Rationale High-dependency care units (HDUs), also termed “intermediate care units”, “step-down units”, or “respiratory HDUs”, are areas in which degrees of patient care and costs are between those of the intensive care unit (ICU) and the general ward. In general, patients requiring mechanical ventilation are treated in the ICU rather than in the HDU, except for the use of HDU beds as surge capacity beds during a massive strain; however, the HDU, as well as ICU, are used as the standard care units for mechanically ventilated patients with coronavirus disease (COVID-19) in Japan. Objectives To assess the outcomes of patients with COVID-19 with invasive mechanical ventilation treated in the HDU versus those treated in the ICU. Methods In this retrospective cohort study, we used a multicenter inpatient database in Japan to identify mechanically ventilated patients with COVID-19 in the ICU or HDU on the start day of invasive mechanical ventilation from February 10, 2020, to November 30, 2021. The primary outcome was in-hospital mortality within 30 days from the start of the first invasive mechanical ventilation. Propensity score matching was performed to compare the outcomes of patients treated in the ICU with those treated in the HDU. Results Of 1,985 eligible patients with COVID-19 with invasive mechanical ventilation, 1,303 (66%) were treated in the ICU, and 682 (34%) were treated in the HDU on the start day of invasive mechanical ventilation. After propensity score matching, patients treated in the ICU had significantly lower in-hospital mortality within 30 days than those treated in the HDU (18.3% vs. 24.2%; risk difference, −5.8%; 95% confidence interval, −10.9% to −0.8%). Conclusions This multicenter observational study in Japan suggests that care for mechanically ventilated patients with COVID-19 in the ICU may significantly reduce in-hospital mortality within 30 days compared with care in the HDU. Establishing a critical care system that would allow patients with COVID-19 requiring ventilators to be treated in the ICU is desirable. Because this study was an observational study, our finding represents an association, not causation. Further studies of different critical care systems are warranted to confirm our findings.
4 citations
2 citations
TL;DR: In this paper , the authors evaluated the data of patients that were hospitalized in IICU and found that the need for an intensive care unit has increased during the pandemic of coronavirus disease.
Abstract: Objectives: The need for an intensive care unit has increased during the pandemic of coronavirus disease (COVID-19). For this reason, intermediate-level intensive care units (IICUs) were established in hospitals worldwide. This study aims to evaluate the data of patients that hospitalized in IICU.
Methods: Patients under treatment for COVID-19 were followed up in IICU after the negative polymerized chain reaction test. A total of 52 patients were evaluated retrospectively between August 24, 2020 and March 1, 2021. The patients were divided into two groups according to discharge status from IICU (Group 1: exitus, Group 2: transferred to clinic, or discharged home). Demographic data, comorbidities, Acute Physiology and Chronic Health Evaluation II (APACHE II), Glasgow Coma Scale (GCS), treatments and procedures, and complications were recorded.
Results: Seventeen (32.7%) of 52 patients who were followed up in IICU died. Thirty-five patients (67.3%) were transferred to the clinic or discharged home. The APACHE II scores at admission to IICU were higher in Group 1 (26.11 ± 5.86) than in Group 2 (23.43 ± 6.32) but not statistically significant. GCS was statistically significantly lower in Group 1 than in Group 2 (7.82 ± 2.42 and 10.25 ± 2.58, respectively, p = 0.002). Mechanical ventilation rate (82.3%) and the need for inotropic agents (76.5%) were higher in Group 1 (p = 0,034 and p < 0.001, respectively). Tracheostomy was applied to 5 of all patients, and percutaneous endoscopic gastrostomy was performed 4 of them.
Conclusions: We think that IICU created during the pandemic provides effective treatment for patients needing intensive care. We think IICU is beneficial in providing quick patient discharge in tertiary intensive care units.
TL;DR: In this article , the authors present a series of questions and answers on the history of the UCRI, in addition to the criteria for admission, infrastructure, human and technical resources, and the types of existing units.
Abstract: Las unidades de cuidados respiratorios intermedios (UCRI) son áreas de monitorización y atención especializada de pacientes con insuficiencia respiratoria aguda o crónica-agudizada, cuya gravedad no precisa de ingreso en una unidad de cuidados intensivos, pero por cuya complejidad tampoco pueden ser tratados en planta de hospitalización convencional. Si bien la pandemia por COVID-19 ha demostrado su utilidad en el manejo del paciente respiratorio crítico, la trayectoria histórica de las UCRI viene de muchos años atrás, en los que se ha demostrado su coste-efectividad con creces. El presente documento presenta una serie de preguntas y respuestas sobre la historia de las UCRI, además de los criterios de admisión, infraestructura, recursos humanos y técnicos y los tipos de unidades existentes. En el seno del Año UCRI 2021-2022 designado por la Sociedad Española de Neumología y Cirugía Torácica, es oportuna toda divulgación científica vinculada al conocimiento en profundidad de estas unidades, donde confluyen la multidisciplinariedad y el trabajo de profesionales relacionados con el cuidado del paciente respiratorio crítico. The intermediate respiratory care units (UCRI) are areas of monitoring and specialized care of patients with acute or chronic-exacerbated respiratory failure, whose severity does not require admission to an intensive care unit, but which due to their complexity cannot be treated in conventional hospitalization. Although the COVID-19 pandemic has proven its usefulness in the management of critical respiratory patients, the historical trajectory of the UCRI comes from many years ago, in which its cost-effectiveness has been demonstrated by far. This document presents a series of questions and answers on the history of the UCRI, in addition to the criteria for admission, infrastructure, human and technical resources, and the types of existing Units. Within the UCRI year 2021-2022 designated by the Spanish Society of Pneumology and Thoracic Surgery, any scientific dissemination linked to the in-depth knowledge of these units is timely, where multidisciplinarity and the work of professionals related to the care of critical respiratory patients converge.
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TL;DR: Hospitalised COVID-19 patients are frequently elderly subjects with co-morbidities receiving polypharmacy, all of which are known risk factors for d
Abstract: Background: Hospitalised COVID-19 patients are frequently elderly subjects with co-morbidities receiving polypharmacy, all of which are known risk factors for d
14,343 citations
University of Milan1, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico2, Vita-Salute San Raffaele University3, Catholic University of the Sacred Heart4, Agostino Gemelli University Polyclinic5, Ospedale di Circolo e Fondazione Macchi6, University of Milano-Bicocca7, University of Pavia8, University of Brescia9, Kessler Foundation10, University of Bologna11, Humanitas University12
TL;DR: Patients with coronavirus disease 2019 (COVID-19) requiring treatment in an intensive care unit (ICU) in the Lombardy region of Italy were characterized, including data on clinical management, respiratory failure, and patient mortality.
Abstract: Importance In December 2019, a novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) emerged in China and has spread globally, creating a pandemic. Information about the clinical characteristics of infected patients who require intensive care is limited. Objective To characterize patients with coronavirus disease 2019 (COVID-19) requiring treatment in an intensive care unit (ICU) in the Lombardy region of Italy. Design, Setting, and Participants Retrospective case series of 1591 consecutive patients with laboratory-confirmed COVID-19 referred for ICU admission to the coordinator center (Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy) of the COVID-19 Lombardy ICU Network and treated at one of the ICUs of the 72 hospitals in this network between February 20 and March 18, 2020. Date of final follow-up was March 25, 2020. Exposures SARS-CoV-2 infection confirmed by real-time reverse transcriptase–polymerase chain reaction (RT-PCR) assay of nasal and pharyngeal swabs. Main Outcomes and Measures Demographic and clinical data were collected, including data on clinical management, respiratory failure, and patient mortality. Data were recorded by the coordinator center on an electronic worksheet during telephone calls by the staff of the COVID-19 Lombardy ICU Network. Results Of the 1591 patients included in the study, the median (IQR) age was 63 (56-70) years and 1304 (82%) were male. Of the 1043 patients with available data, 709 (68%) had at least 1 comorbidity and 509 (49%) had hypertension. Among 1300 patients with available respiratory support data, 1287 (99% [95% CI, 98%-99%]) needed respiratory support, including 1150 (88% [95% CI, 87%-90%]) who received mechanical ventilation and 137 (11% [95% CI, 9%-12%]) who received noninvasive ventilation. The median positive end-expiratory pressure (PEEP) was 14 (IQR, 12-16) cm H2O, and Fio2was greater than 50% in 89% of patients. The median Pao2/Fio2was 160 (IQR, 114-220). The median PEEP level was not different between younger patients (n = 503 aged ≤63 years) and older patients (n = 514 aged ≥64 years) (14 [IQR, 12-15] vs 14 [IQR, 12-16] cm H2O, respectively; median difference, 0 [95% CI, 0-0];P = .94). Median Fio2was lower in younger patients: 60% (IQR, 50%-80%) vs 70% (IQR, 50%-80%) (median difference, −10% [95% CI, −14% to 6%];P = .006), and median Pao2/Fio2was higher in younger patients: 163.5 (IQR, 120-230) vs 156 (IQR, 110-205) (median difference, 7 [95% CI, −8 to 22];P = .02). Patients with hypertension (n = 509) were older than those without hypertension (n = 526) (median [IQR] age, 66 years [60-72] vs 62 years [54-68];P Conclusions and Relevance In this case series of critically ill patients with laboratory-confirmed COVID-19 admitted to ICUs in Lombardy, Italy, the majority were older men, a large proportion required mechanical ventilation and high levels of PEEP, and ICU mortality was 26%.
4,331 citations
851 citations
McMaster University1, Copenhagen University Hospital2, King Saud bin Abdulaziz University for Health Sciences3, Albert Einstein College of Medicine4, University of Toronto5, Brown University6, Utrecht University7, NewYork–Presbyterian Hospital8, Peking Union Medical College Hospital9, Sunnybrook Health Sciences Centre10, University of Ulsan11, National Institutes of Health12, Imperial College London13, United Arab Emirates University14, Humanitas University15, St George’s University Hospitals NHS Foundation Trust16, Emory University Hospital17, University at Buffalo18, Baylor College of Medicine19, University of Milano-Bicocca20, King Abdulaziz Medical City21, King Saud Medical City22, The George Institute for Global Health23, University of Virginia24, University of Washington25
TL;DR: A panel of 36 experts from 12 countries issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19, and assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach.
Abstract: BACKGROUND: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed. METHODS: We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations. RESULTS: The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which four are best practice statements, nine are strong recommendations, and 35 are weak recommendations. No recommendation was provided for six questions. The topics were: 1) infection control, 2) laboratory diagnosis and specimens, 3) hemodynamic support, 4) ventilatory support, and 5) COVID-19 therapy. CONCLUSION: The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new evidence in further releases of these guidelines.
832 citations
TL;DR: Treatment with helmet NIV resulted in a significant reduction of intubation rates among patients with ARDS and a statistically significant reduction in 90-day mortality.
Abstract: Importance Noninvasive ventilation (NIV) with a face mask is relatively ineffective at preventing endotracheal intubation in patients with acute respiratory distress syndrome (ARDS). Delivery of NIV with a helmet may be a superior strategy for these patients. Objective To determine whether NIV delivered by helmet improves intubation rate among patients with ARDS. Design, Setting, and Participants Single-center randomized clinical trial of 83 patients with ARDS requiring NIV delivered by face mask for at least 8 hours while in the medical intensive care unit at the University of Chicago between October 3, 2012, through September 21, 2015. Interventions Patients were randomly assigned to continue face mask NIV or switch to a helmet for NIV support for a planned enrollment of 206 patients (103 patients per group). The helmet is a transparent hood that covers the entire head of the patient and has a rubber collar neck seal. Early trial termination resulted in 44 patients randomized to the helmet group and 39 to the face mask group. Main Outcomes and Measures The primary outcome was the proportion of patients who required endotracheal intubation. Secondary outcomes included 28-day invasive ventilator–free days (ie, days alive without mechanical ventilation), duration of ICU and hospital length of stay, and hospital and 90-day mortality. Results Eighty-three patients (45% women; median age, 59 years; median Acute Physiology and Chronic Health Evaluation [APACHE] II score, 26) were included in the analysis after the trial was stopped early based on predefined criteria for efficacy. The intubation rate was 61.5% (n = 24) for the face mask group and 18.2% (n = 8) for the helmet group (absolute difference, −43.3%; 95% CI, −62.4% to −24.3%; P P P = .02). Adverse events included 3 interface-related skin ulcers for each group (ie, 7.6% in the face mask group had nose ulcers and 6.8% in the helmet group had neck ulcers). Conclusions and Relevance Among patients with ARDS, treatment with helmet NIV resulted in a significant reduction of intubation rates. There was also a statistically significant reduction in 90-day mortality with helmet NIV. Multicenter studies are needed to replicate these findings. Trial Registration clinicaltrials.gov Identifier:NCT01680783
425 citations