RESUMEN
BACKGROUND: High frequency percussive ventilation (HFPV) has demonstrated improvements in gas exchange, but not in clinical outcomes. OBJECTIVES: We utilize HFPV in patients failing conventional ventilation (CV), with rescue venovenous extracorporeal membrane oxygenation (VV ECMO) reserved for failure of HFPV, and we describe our experience with such a strategy. METHODS: All adult patients (age >18 years) placed on HFPV for failure of CV at a single institution over a 10-year period were included. Those maintained on HFPV were compared to those that failed HFPV and required VV ECMO. Survival was compared to expected survival after upfront VV ECMO as estimated by VV ECMO risk prediction models. RESULTS: Sixty-four patients were placed on HFPV for failure of CV over a 10-year period. After HFPV initiation, the P/F ratio rose from 76mmHg to 153.3mmHg in the 69 % of patients successfully maintained on HFPV. The P/F ratio only rose from 60.3mmHg to 67mmHg in the other 31 % of patients, and they underwent rescue ECMO with the P/F ratio rising to 261.6mmHg. The P/F ratio continued to improve in HFPV patients, while it declined in ECMO patients, such that at 24 h, the P/F ratio was greater in HFPV patients. The strongest independent predictor of failure of HFPV requiring rescue VV ECMO was a lower pO2 (p = .055). Overall in-hospital survival (59.4 %) was similar to that expected with upfront ECMO (RESP score: 57 %). CONCLUSIONS: HFPV demonstrated significant and sustained improvements in gas exchange and may obviate the need for ECMO and its associated complications.
Asunto(s)
Oxigenación por Membrana Extracorpórea , Ventilación de Alta Frecuencia , Insuficiencia Respiratoria , Adulto , Humanos , Adolescente , Oxigenación por Membrana Extracorpórea/efectos adversos , Ventilación de Alta Frecuencia/efectos adversos , Insuficiencia Respiratoria/terapia , Insuficiencia Respiratoria/etiología , Respiración , Cognición , Estudios RetrospectivosRESUMEN
Objective: To describe the incidence, clinical characteristics, and factors associated with mortality in patients hospitalized for coronavirus disease 2019 (COVID-19) in whom pneumothorax developed. Patients and Methods: This study was a retrospective analysis conducted using a large administrative database of adult patients hospitalized for COVID-19 in the United States from February 1, 2020, to June 10, 2021. We characterized the clinical features of patients in whom pneumothorax developed and the factors associated with mortality and stratified pneumothorax by the timing of the initiation of invasive mechanical ventilation (IMV) and by the time of hospital admission (early versus late). Results: A total of 811,065 adult patients had a positive test result for severe acute respiratory syndrome coronavirus 2, of whom 103,858 (12.8%) were hospitalized. Pneumothorax occurred in 1915 patients (0.24% overall and 1.84% among hospitalized patients). Over time, the use of steroids and remdesivir increased, whereas the use of IMV, pneumothorax rates, and mortality decreased. The clinical characteristics associated with pneumothorax were male sex; the receipt of IMV; and treatment with steroids, remdesivir, or convalescent plasma. Most patients with pneumothorax received IMV, but pneumothorax developed before the initiation of IMV and/or early during hospitalization in majority. Multivariable analysis revealed that pneumothorax increased the risk of death (adjusted hazard ratio [aHR], 1.15; 95% CI, 1.06-1.24). In patients who did not receive IMV, pneumothorax led to nearly twice the mortality (aHR, 1.99; 95% CI, 1.56-2.54). Increased mortality was also noted when pneumothorax occurred before IMV (aHR, 1.37; 95% CI, 1.11-1.69) and within 7 days of hospital admission (aHR, 1.60; 95% CI, 1.29-1.98). Conclusion: The overall incidence of pneumothorax in patients hospitalized for COVID-19 was low. Pneumothorax is an independent risk factor for death.