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      Use of Dexmedetomidine in Early Prone Positioning Combined With High-Flow Nasal Cannula and Non-Invasive Positive Pressure Ventilation in a COVID-19 Positive Patient

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          Abstract

          As the COVID-19 pandemic continues to manifest in our society, we still lack evidence-based treatment guidelines. Current treatment for COVID-19 pneumonia has been modeled from currently established guidelines such as that of acute respiratory distress syndrome (ARDS). COVID-19 pneumonia, also known as SARS-CoV-2, is characterized by severe hypoxia and near-normal respiratory system compliance with a time-related presentation. Dexmedetomidine is a centrally acting alpha-2 receptor agonist that promotes sedative and anxiolytic effects without the risk of respiratory depression and can provide cooperative or semi-rousable sedation. Patients who are developing ARDS secondary to COVID-19 pneumonia have been treated with self-proning intervals in combination with supplementation of oxygenation via high-flow nasal cannula (HFNC) or non-invasive positive pressure ventilation (NIPPV); however, a few patients have poor tolerance to the devices, leading to poor compliance and eventual worsening respiratory symptoms leading to intubation. In the current case report, we detail how a patient was able to successfully be self-proned with proper tolerance to HFNC and NIPPV while using dexmedetomidine, leading to discharge without the need for further oxygen supplementation at home.

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          COVID-19 Does Not Lead to a “Typical” Acute Respiratory Distress Syndrome

          Luciano Gattinoni, Silvia Coppola, Massimo Cressoni … (2020)
          To the Editor: In northern Italy, an overwhelming number of patients with coronavirus disease (COVID-19) pneumonia and acute respiratory failure have been admitted to our ICUs. Attention is primarily focused on increasing the number of beds, ventilators, and intensivists brought to bear on the problem, while the clinical approach to these patients is the one typically applied to severe acute respiratory distress syndrome (ARDS), namely, high positive end-expiratory pressure (PEEP) and prone positioning. However, the patients with COVID-19 pneumonia, despite meeting the Berlin definition of ARDS, present an atypical form of the syndrome. Indeed, the primary characteristic we are observing (and has been confirmed by colleagues in other hospitals) is a dissociation between their relatively well-preserved lung mechanics and the severity of hypoxemia. As shown in our first 16 patients (Figure 1), a respiratory system compliance of 50.2 ± 14.3 ml/cm H2O is associated with a shunt fraction of 0.50 ± 0.11. Such a wide discrepancy is virtually never seen in most forms of ARDS. Relatively high compliance indicates a well-preserved lung gas volume in this patient cohort, in sharp contrast to expectations for severe ARDS. Figure 1. (A) Distributions of the observations of the compliance values observed in our cohort of patients. (B) Distributions of the observations of the right-to-left shunt values observed in our cohort of patients. A possible explanation for such severe hypoxemia occurring in compliant lungs is a loss of lung perfusion regulation and hypoxic vasoconstriction. Actually, in ARDS, the ratio of the shunt fraction to the fraction of gasless tissue is highly variable, with a mean of 1.25 ± 0.80 (1). In eight of our patients with a computed tomography scan, however, we measured a ratio of 3.0 ± 2.1, suggesting a remarkable hyperperfusion of gasless tissue. If this is the case, the increases in oxygenation with high PEEP and/or prone positioning are not primarily due to recruitment, the usual mechanism in ARDS (2), but instead, in these patients with poorly recruitable lungs (3), result from the redistribution of perfusion in response to pressure and/or gravitational forces. We should consider that 1) in patients who are treated with continuous positive airway pressure or noninvasive ventilation and who present with clinical signs of excessive inspiratory efforts, intubation should be prioritized to avoid excessive intrathoracic negative pressures and self-inflicted lung injury (4); 2) high PEEP in a poorly recruitable lung tends to result in severe hemodynamic impairment and fluid retention; and 3) prone positioning of patients with relatively high compliance provides a modest benefit at the cost of a high demand for stressed human resources. Given the above considerations, the best we can do while ventilating these patients is to “buy time” while causing minimal additional damage, by maintaining the lowest possible PEEP and gentle ventilation. We need to be patient.
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            High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure.

            Jean-Pierre Frat, Arnaud W Thille, Alain Mercat … (2015)
            Whether noninvasive ventilation should be administered in patients with acute hypoxemic respiratory failure is debated. Therapy with high-flow oxygen through a nasal cannula may offer an alternative in patients with hypoxemia.
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              Early Self‐Proning in Awake, Non‐intubated Patients in the Emergency Department: A Single ED’s Experience During the COVID‐19 Pandemic

              Nicholas D. Caputo, Reuben Strayer, Richard E. Levitan (2020)
              Abstract Objective Prolonged and unaddressed hypoxia can lead to poor patient outcomes. Proning has become a standard treatment in the management of patients with ARDS who have difficulty achieving adequate oxygen saturation. The purpose of this study was to describe the use of early proning of awake, non‐intubated patients in the emergency department (ED) during the COVID‐19 pandemic. Methods This pilot study was carried out in a single urban ED in New York City. We included patients suspected of having COVID‐19 with hypoxia on arrival. A standard pulse oximeter was used to measure SpO2. SpO2 measurements were recorded at triage and after 5 minutes of proning. Supplemental oxygenation methods included non‐rebreather mask (NRB) and nasal cannula. We also characterized post‐proning failure rates of intubation within the first 24 hours of arrival to the ED. Results Fifty patients were included. Overall, the median SpO2 at triage was 80% (IQR 69 to 85). After application of supplemental oxygen was given to patients on room air it was 84% (IQR 75 to 90). After 5 minutes of proning was added SpO2 improved to 94% (IQR 90 to 95). Comparison of the pre‐ to post‐median by the Wilcoxon Rank‐sum test yielded P = 0.001. Thirteen patients (24%) failed to improve or maintain their oxygen saturations and required endotracheal intubation within 24 hours of arrival to the ED. Conclusion Awake early self‐proning in the emergency department demonstrated improved oxygen saturation in our COVID‐19 positive patients. Further studies are needed to support causality and determine the effect of proning on disease severity and mortality.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cureus
                Journal ID (iso-abbrev): Cureus
                Journal ID (issn): 2168-8184
                Title: Cureus
                Publisher: Cureus (Palo Alto (CA) )
                ISSN (Electronic): 2168-8184
                Publication date (Electronic, pub): 13 September 2020
                Publication date (Electronic, collection): September 2020
                Volume: 12
                Issue: 9
                Electronic Location Identifier: e10430
                Affiliations
                [1 ] Internal Medicine, HCA/University of Central Florida Consortium, Ocala Regional Medical Center, Ocala, USA
                [2 ] Pulmonary and Critical Care, HCA/University of Central Florida Consortium, Ocala Regional Medical Center, Ocala, USA
                Author notes
                Article
                DOI: 10.7759/cureus.10430
                PMC ID: 7556685
                SO-VID: c8e8c097-da8c-4f26-aa77-f956404b48e4
                Copyright © Copyright © 2020, Cruz Salcedo et al.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 16 August 2020
                Date accepted : 4 September 2020
                Categories
                Subject: Internal Medicine
                Subject: Infectious Disease
                Subject: Pulmonology

                Keywords: covid 19,prone positioning,self prone,ards (acute respiratory distress syndrome),covid-19 respiratory failure,high flow nasal cannula,non-invasive positive pressure ventilation,dexmedetomidine
                Data availability:
                Keywords: covid 19, prone positioning, self prone, ards (acute respiratory distress syndrome), covid-19 respiratory failure, high flow nasal cannula, non-invasive positive pressure ventilation, dexmedetomidine

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