Comparison of Noninvasive Mechanical Ventilation With High-Flow Nasal Cannula, Face-Mask, and Helmet in Hypoxemic Respiratory Failure in Patients With COVID-19: A Randomized Controlled Trial.

OBJECTIVES: For COVID-19-related respiratory failure, noninvasive respiratory assistance via a high-flow nasal cannula (HFNC), helmet, and face-mask noninvasive ventilation is used. However, which of these options is most effective is yet to be determined. This study aimed to compare the three techniques of noninvasive respiratory support and to determine the superior technique. DESIGN: A randomized control trial with permuted block randomization of nine cases per block for each parallel, open-labeled arm. SETTING AND PATIENTS: Adult patients with COVID-19 with a Pa o2 /F io2 ratio of less than 300, admitted between February 4, 2021, and August 9, 2021, to three tertiary centers in Oman, were studied. INTERVENTIONS: This study included three interventions: HFNC ( n = 47), helmet continuous positive airway pressure (CPAP; n = 52), and face-mask CPAP ( n = 52). MEASUREMENTS AND MAIN RESULTS: The endotracheal intubation rate and mortality at 28 and 90 days were measured as the primary and secondary outcomes, respectively. Of the 159 randomized patients, 151 were analyzed. The median age was 52 years, and 74% were men. The endotracheal intubation rates were 44%, 45%, and 46% ( p = 0.99), and the median intubation times were 7.0, 5.5, and 4.5 days ( p = 0.11) in the HFNC, face-mask CPAP, and helmet CPAP, respectively. In comparison to face-mask CPAP, the relative risk of intubation was 0.97 (95% CI, 0.63-1.49) for HFNC and 1.0 (95% CI 0.66-1.51) for helmet CPAP. The mortality rates were 23%, 32%, and 38% at 28 days ( p = 0.24) and 43%, 38%, and 40% ( p = 0.89) at 90 days for HFNC, face-mask CPAP, and helmet CPAP, respectively. The trial was stopped prematurely because of a decline in cases. CONCLUSIONS: This exploratory trial found no difference in intubation rate and mortality among the three intervention groups for the COVID-19 patients with hypoxemic respiratory failure; however, more evidence is needed to confirm these findings as the trial was aborted prematurely.

Evaluation of Risk Factors of Snake Envenomation and Associated Complications Presenting to Two Emergency Departments in Oman.

Objectives: To assess the risk factors of snake envenomation and the associated complications that patients present with, using data from two different emergency departments in Oman. The secondary aim was to describe the common characteristics of the presenting patients. Methods: This multicenter retrospective observational study reviewed all cases presenting with symptoms of snakebite to the emergency departments of Sultan Qaboos University Hospital (tertiary) from March 2016 until August 2017 and Rustaq Hospital (secondary) from August 2015 to August 2017. Results: A total of 212 cases met the inclusion criteria. Coagulopathy was observed in 82 (38.7%) patients, while 14 (6.6%) had acute kidney injury (AKI) and 5 (2.4%) had external bleeding. Of the patients who developed AKI, 85.7% (p < 0.001) had encountered the snake in a valley and initially had bleeding from the site of the bite (p < 0.001) and vomiting (p < 0.007). The delay in receiving the anti-snake venom (ASV) increased the risk of AKI (p < 0.016). Of the patients who developed coagulopathy, 47.6% (p < 0.001) had encountered the snake on a farm and 72.0% (p < 0.002) received the bite to a lower limb. Increased time from bite to ASV was associated with development of coagulopathy (p < 0.001). No patient death was recorded. Conclusions: The location (terrain) where the snake was encountered was associated with the patient's risk for either AKI or coagulopathy, which suggests the preference of different snake species to different types of habitat. The time elapsed between the bite and the ASV administration was associated with higher risk of development of AKI or coagulopathy.