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Refractory Acute Respiratory Distress Syndrome Secondary to COVID-19 Successfully Extubated to Average Volume-assured Pressure Support Non-invasive Ventilator.
Cureus. 2020 Apr 27; 12(4):e7849.C

Abstract

Coronavirus disease 2019 (COVID-19) is a respiratory illness caused by the highly infectious novel SARS-CoV-2 coronavirus spread by droplet transmission. Consequently, the use of respiratory devices that may potentially promote aerosolization like non-invasive positive pressure ventilation (NIPPV) for diseases such as obstructive sleep apnea (OSA), advanced chronic obstructive lung disease, pulmonary hypertension (PH), and neuromuscular respiratory disease has been called into question. We present a case of a patient with history of OSA and PH convalescing from refractory acute respiratory distress syndrome (ARDS) secondary to COVID-19 who was successfully extubated to average volume-assured pressure support (AVAPS). A 74-year-old male with medical history notable for OSA on NIPPV, PH, and hypertension presented with respiratory failure secondary to COVID-19 confirmed on polymerase chain reaction (PCR) test. His respiratory status worsened leading to ARDS requiring intubation. He was initially extubated to high flow nasal cannula (HFNC) due to hospital policy to avoid NIPPV due to concerns of viral dissemination. He did not tolerate HFNC and required re-intubation for prolonged period. He was then medically optimized for a second attempt and extubated two days later to AVAPS with an anti-viral filter and negative pressure room with a goal of optimizing his critical illness myopathy and pre-existing OSA and PH. He tolerated extubation well, and over the next five days was weaned from alternating AVAPS/HFNC to eventually requiring two liters nasal cannula in the day and AVAPS mode at night. This case highlights a potential therapeutic option for patients with severe respiratory failure secondary to COVID-19. This patient's pre-existing comorbidities of OSA and PH markedly increased his risk for extubation failure on HFNC. The use of AVAPS after his second extubation attempt helped ensure ventilation and oxygenation non-invasively. COVID-19 can lead to prolonged dependence on mechanical ventilation. This pandemic has the potential to create medical resource scarcities, especially in rural areas where ventilators and trained personnel are already in short supply. By using AVAPS mode, this patient was able to rehabilitate his myopathy and participate in intermittent weaning of HFNC to ultimately simple nasal cannula. AVAPS is useful tool to facilitate extubation, as it allows non-invasive support of respiratory dynamics, particularly in those with co-morbidities such as OSA and PH. Further, larger scale studies are needed to determine its exact role during the COVID-19 pandemic.

Authors+Show Affiliations

Pulmonary, Critical Care & Sleep Medicine, West Virginia University, Morgantown, USA.Internal Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, West Virginia University, Morgantown, USA.Internal Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, West Virginia University, Morgantown, USA.Internal Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, West Virginia University, Morgantown, USA.Internal Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, West Virginia University, Morgantown, USA.

Pub Type(s)

Case Reports

Language

eng

PubMed ID

32483500

Citation

Mittal, Abhinav, et al. "Refractory Acute Respiratory Distress Syndrome Secondary to COVID-19 Successfully Extubated to Average Volume-assured Pressure Support Non-invasive Ventilator." Cureus, vol. 12, no. 4, 2020, pp. e7849.
Mittal A, Forte M, Leonard R, et al. Refractory Acute Respiratory Distress Syndrome Secondary to COVID-19 Successfully Extubated to Average Volume-assured Pressure Support Non-invasive Ventilator. Cureus. 2020;12(4):e7849.
Mittal, A., Forte, M., Leonard, R., Sangani, R., & Sharma, S. (2020). Refractory Acute Respiratory Distress Syndrome Secondary to COVID-19 Successfully Extubated to Average Volume-assured Pressure Support Non-invasive Ventilator. Cureus, 12(4), e7849. https://doi.org/10.7759/cureus.7849
Mittal A, et al. Refractory Acute Respiratory Distress Syndrome Secondary to COVID-19 Successfully Extubated to Average Volume-assured Pressure Support Non-invasive Ventilator. Cureus. 2020 Apr 27;12(4):e7849. PubMed PMID: 32483500.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Refractory Acute Respiratory Distress Syndrome Secondary to COVID-19 Successfully Extubated to Average Volume-assured Pressure Support Non-invasive Ventilator. AU - Mittal,Abhinav, AU - Forte,Michael, AU - Leonard,Rachel, AU - Sangani,Rahul, AU - Sharma,Sunil, Y1 - 2020/04/27/ PY - 2020/6/3/entrez PY - 2020/6/3/pubmed PY - 2020/6/3/medline KW - avaps KW - covid 19 KW - critical illness myopathy KW - non-invasive mechanical ventilation KW - pulmonary hypertension KW - sars-cov-2 KW - worsening obstructive sleep apnea (osa) SP - e7849 EP - e7849 JF - Cureus JO - Cureus VL - 12 IS - 4 N2 - Coronavirus disease 2019 (COVID-19) is a respiratory illness caused by the highly infectious novel SARS-CoV-2 coronavirus spread by droplet transmission. Consequently, the use of respiratory devices that may potentially promote aerosolization like non-invasive positive pressure ventilation (NIPPV) for diseases such as obstructive sleep apnea (OSA), advanced chronic obstructive lung disease, pulmonary hypertension (PH), and neuromuscular respiratory disease has been called into question. We present a case of a patient with history of OSA and PH convalescing from refractory acute respiratory distress syndrome (ARDS) secondary to COVID-19 who was successfully extubated to average volume-assured pressure support (AVAPS). A 74-year-old male with medical history notable for OSA on NIPPV, PH, and hypertension presented with respiratory failure secondary to COVID-19 confirmed on polymerase chain reaction (PCR) test. His respiratory status worsened leading to ARDS requiring intubation. He was initially extubated to high flow nasal cannula (HFNC) due to hospital policy to avoid NIPPV due to concerns of viral dissemination. He did not tolerate HFNC and required re-intubation for prolonged period. He was then medically optimized for a second attempt and extubated two days later to AVAPS with an anti-viral filter and negative pressure room with a goal of optimizing his critical illness myopathy and pre-existing OSA and PH. He tolerated extubation well, and over the next five days was weaned from alternating AVAPS/HFNC to eventually requiring two liters nasal cannula in the day and AVAPS mode at night. This case highlights a potential therapeutic option for patients with severe respiratory failure secondary to COVID-19. This patient's pre-existing comorbidities of OSA and PH markedly increased his risk for extubation failure on HFNC. The use of AVAPS after his second extubation attempt helped ensure ventilation and oxygenation non-invasively. COVID-19 can lead to prolonged dependence on mechanical ventilation. This pandemic has the potential to create medical resource scarcities, especially in rural areas where ventilators and trained personnel are already in short supply. By using AVAPS mode, this patient was able to rehabilitate his myopathy and participate in intermittent weaning of HFNC to ultimately simple nasal cannula. AVAPS is useful tool to facilitate extubation, as it allows non-invasive support of respiratory dynamics, particularly in those with co-morbidities such as OSA and PH. Further, larger scale studies are needed to determine its exact role during the COVID-19 pandemic. SN - 2168-8184 UR - https://www.unboundmedicine.com/medline/citation/32483500/Refractory_Acute_Respiratory_Distress_Syndrome_Secondary_to_COVID_19_Successfully_Extubated_to_Average_Volume_assured_Pressure_Support_Non_invasive_Ventilator_ L2 - https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/32483500/ DB - PRIME DP - Unbound Medicine ER -
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