Early versus late tracheal intubation in COVID-19 patients: a "pros/cons" debate also considering heart-lung interactions.

The best timing of orotracheal intubation and invasive ventilation in COVID-19 patients with acute respiratory distress syndrome is unknown. The use of non-invasive ventilation, a life-saving technique in many medical conditions, is debated in patients with ARDS since prolonged NIV and delayed intubation may be harmful. Shortage of intensive care beds and ventilators during a respiratory pandemic can trigger a widespread use of early non-invasive ventilation in many hospitals but which is the best way to ventilate patients with severe bilateral pneumonia and severely increased spontaneous ventilation is controversial. Moreover, viral spreading to health-care workers and other hospitalized patients is an issue for any device used to administer oxygen. Even if protective mechanical ventilation is currently the gold standard for the management of acute respiratory distress syndrome, tracheal intubation is not without risks and is associated with delirium, hemodynamic instability, immobilization and post intensive care syndrome. Both invasive and non-invasive ventilation are associated with advantages and limitations that should be carefully considered when patients with COVID-19-ARDS need our attention. In the absence of strong evidence, in this review we highlight all the pro and con of these two different approaches.

Postoperative Analgesia after Laparoscopic Ovarian Cyst Resection: Double-blind Multicenter Randomized Control Trial Comparing Intraperitoneal Nebulization and Peritoneal Instillation of Ropivacaine.

STUDY OBJECTIVE: To compare the effects of local anesthetic intraperitoneal nebulization with intraperitoneal instillation during laparoscopic ovarian cystectomy on postoperative morphine consumption and pain. DESIGN: Multicenter, randomized, case-control trial. DESIGN CLASSIFICATION: Canadian Task Force Classification I. SETTING: University hospitals in Italy. PATIENTS: One hundred forty patients scheduled for laparoscopic ovarian cystectomy. INTERVENTIONS: Patients were randomized to receive either nebulization of ropivacaine 150 mg before surgery or instillation of ropivacaine 150 mg before surgery. Nebulization was performed using the Aeroneb Pro device (Aerogen, Galway, Ireland). MEASUREMENTS AND MAIN RESULTS: One hundred forty patients were enrolled, and 123 completed the study. There was no difference between the 2 groups in average morphine consumption (7.3 ± 7.5 mg in the nebulization group vs 9.2 ± 7.2 mg in the instillation group; p = .17). Eighty-two percent of patients in the nebulization group required morphine compared with 96% in the instillation group (p < .05). Patients receiving nebulization had a lower dynamic Numeric Ranking Scale compared with those in the instillation group in the postanesthesia care unit postanesthesia care unit and 4 hours after surgery (p < .05). Ten patients (15%) in the nebulization group experienced shivering in the postanesthesia care unit compared with 2 patients (4%) in the instillation group (p = .035). CONCLUSION: Nebulization of ropivacaine prevents the use of morphine in a significant proportion of patients, reduced postoperative pain during the first hours after surgery, and was associated with a higher incidence of postoperative shivering when compared with instillation.