Yoğun Bakımda COVID-19 Hastalarında Oksijenizasyon Yöntemleri
Özet
Covid-19 enfeksiyonu, hafif tablolardan ağır pnömoni ve akut solunum sıkıntısı sendromuna (ARDS) kadar değişen ve yoğun bakım ihtiyacı doğuran hipoksik solunum yetmezliğine yol açabilmektedir. Bu süreçte hastalara oksijen satürasyonunu %90'ın üzerinde tutmak amacıyla konvansiyonel düşük akımlı oksijen desteği, yüksek akımlı nasal kanül tedavisi (YANKOT), non-invaziv mekanik ventilasyon (NIMV) ve invaziv mekanik ventilasyon (IMV) yöntemleri uygulanır. KOT yetersiz kaldığında devreye giren YANKOT, ısıtılmış ve nemlendirilmiş yüksek akımlı oksijen sağlayarak solunum iş yükünü azaltır ve entübasyon ihtiyacını düşürür. Maske veya kask yardımıyla pozitif basınç sağlayan NIMV ise atelektazileri önleyerek oksijenizasyonu iyileştirir. Ayrıca uyanık veya entübe hastalarda uygulanan prone (yüz üstü) pozisyonu, akciğerin dorsal alanlarındaki perfüzyon ve ventilasyonu eşitleyerek oksijenizasyonu belirgin şekilde artırır. Tedavilerin başarısını öngörmede ROX ve HACOR indeksleri gibi klinik parametreler kritik rol oynar. Solunum destek süreçlerindeki en hayati unsur, aerosol yayılımına karşı sağlık personelinin korunması ve hastaların entübasyon ihtiyacının geciktirilmeden zamanında tespit edilmesidir; çünkü geç kalınmış entübasyon mortalite oranlarını doğrudan artırmaktadır.
Covid-19 infection can lead to hypoxic respiratory failure requiring intensive care, ranging from mild tables to severe pneumonia and acute respiratory distress syndrome (ARDS). During this process, conventional low-flow oxygen support, high-flow nasal cannula oxygen therapy (HFNC), non-invasive mechanical ventilation (NIMV), and invasive mechanical ventilation (IMV) are applied to maintain oxygen saturation above 90%. HFNC, which steps in when conventional therapy is insufficient, reduces the respiratory workload and decreases the need for intubation by providing heated and humidified high-flow oxygen. NIMV, providing positive pressure via mask or helmet, improves oxygenation by preventing atelectasis. Furthermore, the prone position applied to awake or intubated patients significantly enhances oxygenation by balancing perfusion and ventilation in the dorsal areas of the lungs. Clinical parameters such as ROX and HACOR indexes play a critical role in predicting treatment success. The most vital element in respiratory support processes is protecting healthcare workers against aerosol transmission and detecting the patient's need for intubation in a timely manner without delay, as delayed intubation directly increases mortality rates.
Referanslar
Wu Z, McGoogan JM. Characteristics of and important lessons from the Coronavirus Disease 2019 (COVID-19) outbreak in china: summary of a report of 72314 cases from the Chinese center for disease control and prevention.JAMA. 2020;323(13):1239-1242. doi:10.1001/jama.2020.2648
Li J, Huang DQ, Zou B, et al. Epidemiology of COVID-19: A systematic review and meta-analysis of clinical characteristics, risk factors, and outcomes. J Med Virol. 2021 Mar;93(3):1449-1458. doi: 10.1002/jmv.26424.
Dessie Z, Zewotir T. Mortality-related risk factors of COVID-19: a systematic review and meta-analysis of 42 studies and 423,117 patients. BMC Infect Dis. 2021 Aug 21;21(1):855. doi: 10.1186/s12879-021-06536-3.
Gattinoni L, Coppola S, Cressoni M, et al. Covid-19 does not lead to a “Typical” Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2020 May 15;201(10):1299-1300. doi: 10.1164/rccm.202003-0817LE.
Gattinoni L, Chiumello D, Caironi P, et al. COVID-19 pneumonia: different respiratory treatments for different phenotypes? Intensive Care Med. 2020 Jun;46(6):1099-1102. doi: 10.1007/s00134-020-06033-2.
Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020 Mar 17;323(11):1061-1069. doi: 10.1001/jama.2020.1585.
Greenhalgh T, Knight M, Inda-Kim M, et al. Remote management of covid-19 using home pulse oximetry and virtual ward support. BMJ. 2021 Mar 25;372:n677. doi: 10.1136/bmj.n677.
Whittle J.S, Pavlov I, Sacchetti A.D, et al. Respiratory support for adult patients with COVID‐19. J Am Coll Emerg Physicians Open. 2020 Apr; 1(2): 95–101. doi: 10.1002/emp2.12071
Ersoy EO, Topeli A. Solunum yetmezliğinde oksijen uygulama sistemleri. Yoğun Bakım Derg 2016; 7: 99-105. doı: 10.5152/dcbybd.2017.1329
Nishimura M. High-Flow Nasal Cannula Oxygen Therapy in Adults: Physiological Benefits, Indication, Clinical Benefits, and Adverse Effects. Respir Care. 2016 Apr;61(4):529-41 doi: 10.4187/respcare.04577
Renda T, Corrado A, Iskandar G, et al. High-flow nasal oxygen therapy in intensive care and anaesthesia. British Journal of Anaesthesia. 2018;120(1):18-27.
Rochwerg B, Granton D, Wang D.X, et al. High flow nasal cannula compared with conventional oxygen therapy for acute hypoxemic respiratory failure: A systematic review and meta-analysis. Intensive Care Med. 2019 May;45(5):563-572. doi: 10.1007/s00134-019-05590-5
Ricard J.D, Roca O, Lemiale V, et al. Use of nasal high flow oxygen during acute respiratory failure. Intensive Care Med. 2020 Dec;46(12):2238-2247. doi: 10.1007/s00134-020-06228-7.
Driscoll BR, Howard LS, Earis J, et al. BMJ Open Respir Res. 2017; 4(1): e000170. doi: 10.1136/bmjresp-2016-000170
Sandeep Sharma; Mauricio Danckers; Devang Sanghavi; Treasure Island (FL): StatPearls Publishing; 2022 Jan-
Oczkowski S, Ergan B, Bos L, et al. ERS Clinical Practice Guidelines: High-flow nasal cannula in acute respiratory failure. Eur Respir J. 2021 Oct 28;2101574. doi: 10.1183/13993003.01574-2021.
Üney İ.H.(2021). Solunum Yetmezliğinde Oksijen Tedavisi. Havva Sayhan Kaplan (Ed.), Solunum Yetmezliği (233-246). Ankara: Akademisyen Kitapevi.
Calligaro GL, Lalla U, Audley G, et al. The utility of high-flow nasal oxygen for severe COVID-19 pneumonia in a resource-constrained setting: A multi-centre prospective observational study. EClinicalMedicine. 2020 Nov;28:100570. doi: 10.1016/j.eclinm.2020.100570
Teng XB, Shen Y, Han MF, et al. The value of high-flow nasal cannula oxygen therapy in treating novel coronavirus pneumonia. Eur J Clin Invest. 2021 Mar;51(3):e13435. doi: 10.1111/eci.13435
Demoule A, Baron AV, Darmon M, et al. High-Flow Nasal Cannula in Critically III Patients with Severe COVID-19. Am J Respir Crit Care Med. 2020 Oct 1; 202(7):1039-1042. doi: 10.1164/rccm.202005-2007LE
Celejewska-Wójcik N, Polok K, Górka K, et al. High-flow nasal oxygen therapy in the treatment of acute respiratory failure in severe COVID-19 pneumonia: a prospective observational study. Pol Arch Intern Med. 2021 Jul 30; 131(7-8):658-665. doi: 10.20452/pamw.16015.
Zucman N, Mullaert J, Roux D, et al. Prediction of outcome of nasal high flow use during COVID-19-related acute hypoxemic respiratory failure. Intensive Care Med. 2020 Oct;46(10):1924-1926. doi: 10.1007/s00134-020-06177-1.
Wang K, Zhao W, Li J, et al. The experience of high-flow nasal cannula in hospitalized patients with 2019 novel coronavirus-infected pneumonia in two hospitals of Chongqing, China. Ann Intensive Care. 2020 Mar 30;10(1):37. doi: 10.1186/s13613-020-00653-z.
Patel M, Gangemi A, Marron R, et al. Retrospective analysis of high flow nasal therapy in COVID-19-related moderate-to-severe hypoxaemic respiratory failure. BMJ Open Respir Res. 2020 Aug;7(1):e000650. doi: 10.1136/bmjresp-2020-000650.
B Sztrymf, J Messika, F Bertrand, et al. Beneficial effects of humidified high flow nasal oxygen in critical care patients: a prospective pilot study. Intensive Care Med. 2011 Nov; 37(11):1780-6. doi: 10.1007/s00134-011-2354-6
G Carteaux, T Millan-Guilarte, N De Prost, et al. Failure of Noninvasive Ventilation for De Novo Acute Hypoxemic Respiratory Failure: Role of Tidal Volume. Crit Care Med. 2016 Feb; 44(2):282-90. doi: 10.1097/CCM.0000000000001379.
Kangelaris KN, Ware LB, Wang CY, et al. Timing of Intubation and Clinical Outcomes in Adults With Acute Respiratory Distress Syndrome. Crit Care Med. 2016 Jan;44(1):120-9. doi: 10.1097/CCM.0000000000001359.
Roca O, Caralt B, Messika J, et al. An Index Combining Respiratory Rate and Oxygenation to Predict Outcome of Nasal High-Flow Therapy. Am J Respir Crit Care Med. 2019 Jun 1;199(11):1368-1376. doi: 10.1164/rccm.201803-0589OC.
Hu M, Zhou Q, Zheng R, et al. Application of high-flow nasal cannula in hypoxemic patients with COVID-19: a retrospective cohort study. BMC Pulm Med. 2020 Dec 24;20(1):324. doi: 10.1186/s12890-020-01354-w.
Xiao-Huan Ma, Meng-Meng An, Fang Yin, et al. Risk factors associated with failure of high-flow nasal cannula oxygen therapy in patients with severe COVID-19 in Wuhan, China. Doi: 10.21203/rs.3.rs-41316/v2
Rorat M, Szymanski W, Jurek T, et al. When Conventional Oxygen Therapy Fails-The Effectiveness of High-Flow Nasal Oxygen Therapy in Patients with Respiratory Failure in the Course of COVID-19. J Clin Med. 2021 Oct 16;10(20):4751. doi: 10.3390/jcm10204751.
Mellado-Artigas R, Ferreyro BL, Angriman F, et al. High-flow nasal oxygen in patients with COVID-19-associated acute respiratory failure. Crit Care. 2021 Feb 11;25(1):58. doi: 10.1186/s13054-021-03469-w.
Perkins GD, Ji C, Connolly BA, et al. An adaptive randomized controlled trial of non-invasive respiratory strategies in acute respiratory failure patients with COVID-19. MedRxiv. (2021) doi: https://doi.org/10.1101/2021.08.02.21261379 (05.02.2022 tarihinde https://www.medrxiv.org/content/10.1101/2021.08.02.21261379v1?rss=1%22&utm_source=dlvr.it&utm_medium=tumblr adresinden ulaşılmıştır)
NICE (2022). The National Institute for Health and Care Excellence. COVID-19 Rapid Guideline: Managing COVID-19. 2022. (05/02/2022 tarihinde https://www.nice.org.uk/guidance/ng191/resources/covid19-rapid-guideline-managing-covid19-pdf-51035553326 adresinden ulaşılmıştır.)
Grieco DL, Menga LS, Cesarano M, et al; COVID-ICU Gemelli Study Group. Effect of helmet noninvasive ventilation vs high-flow nasal oxygen on days free of respiratory support in patients with COVID-19 and moderate to severe hypoxemic respiratory failure: the HENIVOT randomized clinical trial. JAMA. 2021;325(17):1731-1743. doi:10.1001/jama.2021.4682
Chalmers J.D, Crichton M.L, Goeminne P.C, et al. Management of hospitalised adults with coronavirus disease 2019 (COVID-19): a European Respiratory Society living guideline. Eur Respir J. 2021 Apr; 57(4): 2100048. doi: 10.1183/13993003.00048-2021.
Macit Aydın E, Karabıyık L. (2019). Noninvaziv Mekanik Ventilasyon Uygulamaları: Ekipman, Fizyolojik Etkileri, Endikasyonları, Kontrendikasyonları, Yan Etkiler. Zehra Nur Baykara (Ed.), Yoğun Bakımda Noninvaziv Yöntemlerle Solunum Desteği. (S.9-13). Ankara: Türkiye Klinikleri.
Kunter E. (2017). Noninvaziv Mekanik Ventilasyonun Fizyolojik Etkileri ve Endikasyonları. Serpil Öcal (Ed.), Noninvaziv Mekanik Ventilasyon Uygulamaları (11-20). Türkiye Solunum Araştırmaları Derneği.
Grieco DL, Maggiore SM, Roca O, et al. Non-invasive ventilatory support and high-flow nasal oxygen as first-line treatment of acute hypoxemic respiratory failure and ARDS. Intensive Care Med. 2021;47(8):851-866. doi: 10.1007/s00134-021-06459-2.
Liu Q, Gao Y, Chen R, et al. Noninvasive ventilation with helmet versus control strategy in patients with acute respiratory failure: a systematic review and meta-analysis of controlled studies. Crit Care. 2016 Aug 23;20(1):265. doi: 10.1186/s13054-016-1449-4.
Patel BK , Wolfe KS, Pohlman AS, et al. Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome A Randomized Clinical Trial. JAMA. 2016;315(22):2435-2441. doi:10.1001/jama.2016.6338
Grieco DL, Menga LS, Raggi V. Physiological Comparison of High-Flow Nasal Cannula and Helmet Noninvasive Ventilation in Acute Hypoxemic Respiratory Failure. Am J Respir Crit Care Med. 2020 Feb 1;201(3):303-312. doi: 10.1164/rccm.201904-0841OC.
Ferreyro BL, Angriman F, Munshi L, et al. Association of noninvasive oxygenation strategies with all-cause mortality in adults with acute hypoxemic respiratory failure. JAMA. 2020;324:57. doi: 10.1001/jama.2020.9524.
Hui DS, Chow BK, Ng SS, et al. Exhaled air dispersion distances during noninvasive ventilation via different Respironics face masks. Chest. 2009 Oct;136(4):998-1005. doi: 10.1378/chest.09-0434
Cabrini L, Landoni G, Zangrillo A. Minimise nosocomial spread of 2019-nCoV when treating acute respiratory failure. Lancet. 2020 Feb 29;395(10225):685. doi: 10.1016/S0140-6736(20)30359-7.
Vargas F, Thille A, Lyazidi A, et al. Helmet with specific settings versus facemask for noninvasive ventilation. Crit Care Med. 2009 Jun;37(6):1921-8. doi: 10.1097/CCM.0b013e31819fff93.
Schünemann HJ, Khabsa J, Solo K, et al. Ventilation Techniques and Risk for Transmission of Coronavirus Disease, Including COVID-19: A Living Systematic Review of Multiple Streams of Evidence. Ann Intern Med. 2020 Aug 4;173(3):204-216. doi: 10.7326/M20-2306.
Yoshida T, Fujino Y, Amato MBP, Kavanagh BP. Fifty years of research in ARDS. Spontaneous breathing during mechanical ventilation. Risks, mechanisms, and management. Am J Respir Crit Care Med. 2017;195:985–992. doi: 10.1164/rccm.201604-0748CP
Frat J-P, Ragot S, Coudroy R, et al. Predictors of intubation in patients with acute hypoxemic respiratory failure treated with a noninvasive oxygenation strategy. Crit Care Med. 2018;46(2):208–215. doi: 10.1097/CCM.0000000000002818.
Tonelli R, Fantini R, Tabbì L, et al. Early inspiratory effort assessment by esophageal manometry predicts noninvasive ventilation outcome in de novo respiratory failure. A pilot study. Am J Respir Crit Care Med. 2020 Aug 15;202(4):558-567. doi: 10.1164/rccm.201912-2512OC.
Bellani G, Laffey JG, Pham T, et al. Noninvasive Ventilation of Patients with Acute Respiratory Distress Syndrome. Insights from the LUNG SAFE Study. Am J Respir Crit Care Med. 2017 Jan 1;195(1):67-77. doi: 10.1164/rccm.201606-1306OC.
Alhazzani W, Moller MH, Arabi YM, et al. Surviving Sepsis Campaign: Guidelines on the management of critically Ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med. 2020 May;46(5):854-887. doi: 10.1007/s00134-020-06022-5.
Bellani G, Grasselli G, Cecconi M, et al. Noninvasive Ventilatory Support of Patients with COVID-19 outside the Intensive Care Units (WARd-COVID). Ann Am Thorac Soc. 2021 Jun;18(6):1020-1026. doi: 10.1513/AnnalsATS.202008-1080OC
Liu L, Xie J, Wu W, et al. A simple nomogram for predicting failure of non-invasive respiratory strategies in adults with COVID-19: a retrospective multicentre study. Lancet Digit Health. 2021;3:e166–e174. doi: 10.1016/S2589-7500(20)30316-2.
Menga LS, Cese LD, Bongiovanni F,et al. High failure rate of noninvasive oxygenation strategies in critically Ill subjects with acute hypoxemic respiratory failure due to COVID-19. Respir Care. 2021;66:705–714. doi: 10.4187/respcare.08622.
Touchon F, Trigui Y, Prud'homme E, et al. Awake prone positioning for hypoxaemic respiratory failure: past, COVID-19 and perspectives. Eur Respir Rev. 2021 May 5;30(160):210022. doi: 10.1183/16000617.0022-2021.
Tonelli AR, Zein J, Adams Y, et al. Effects of interventions on survival in acute respiratory distress syndrome: an umbrella review of 159 published randomized trials and 29 meta-analyses. Intensive Care Med. 2014;40(6):769-87. doi: 10.1007/s00134-014-3272-1.
Gu´erin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. The New England Journal of Medicine 2013;368 (23): 2159-2168. doi: 10.1056/NEJMoa121410
Chad T, Sampson C. Prone positioning in conscious patients on medical wards: A review of the evidence and its relevance to patients with COVID-19 infection. Clin Med (Lond). 2020 Jul;20(4):e97-e103. doi: 10.7861/clinmed.2020-0179.
Guérin C, Albert RK, Beitler J. Et al. Prone position in ARDS patients: why, when, how and for whom. Intensive Care Med. 2020; 46(12): 2385–2396. doi: 10.1007/s00134-020-06306-w
Scaravilli V, Grasselli G, Castagna L. Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study. J Crit Care. 2015 Dec;30(6):1390-4. doi: 10.1016/j.jcrc.2015.07.008.
Ding L, Wang L, Ma W, et al. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Crit Care. 2020 Jan 30;24(1):28. doi: 10.1186/s13054-020-2738-5.
Coppo A, Bellani G, Winterton D, et al. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): A prospective cohort study. Lancet Respir Med. 2020; 8: 765-74
Elharrar X, Trigui Y, Dols AM, et al. Use of Prone Positioning in Nonintubated Patients With COVID-19 and Hypoxemic Acute Respiratory Failure. JAMA. 2020 Jun 9; 323(22): 2336–2338. doi: 10.1001/jama.2020.8255
Despres C, Brunin Y, Berthier F, et al. Prone positioning combined with high-flow nasal or conventional oxygen therapy in severe Covid-19 patients. Crit Care. 2020 May 26;24(1):256. doi: 10.1186/s13054-020-03001-6.
Ng Z, Tay WC, Benjamin Ho CH. Awake prone positioning for non-intubated oxygen dependent COVID-19 pneumonia patients. Eur Respir J. 2020 Jul 23;56(1):2001198. doi: 10.1183/13993003.01198-2020.
Sartini C, Tresoldi M, Scarpellini P, et al. . Respiratory parameters in patients with COVID-19 after using noninvasive ventilation in the prone position outside the intensive care unit. JAMA 2020; 323: 2338–2340. doi:10.1001/jama.2020.7861
Yoshida T, Tanaka A, Roldan R, et al. Prone position reduces spontaneous inspiratory effort in patients with acute respiratory distress syndrome: a bicenter study. Am J Respir Crit Care Med. 2021;203:1437–1440. doi: 10.1164/rccm.202012-4509LE.
Alhazzani W, Evans L, Alshamsi F, et al. Surviving sepsis campaign guidelines on the management of adults with coronavirus disease 2019 (COVID-19) in the ICU: first update. Crit Care Med. 2021;49:e219–e234. doi: 10.1097/CCM.0000000000004899.
Pavlov I, He H, McNicholas B, et al. Awake prone positioning in non-intubated patients with acute hypoxemic respiratory failure due to COVID-19: a systematic review of proportional outcomes comparing observational studies with and without awake prone positioning in the setting of COVID-19. Resp Care. 2021 doi: 10.4187/respcare.09191
Ferrando C, Artigas RM, Gea A, et al. Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study. Crit Care. 2020; 24: 597. doi: 10.1186/s13054-020-03314-6
Rosén J, von Oelreich E, Fors D, et al. Awake prone positioning in patients with hypoxemic respiratory failure due to COVID-19: the PROFLO multicenter randomized clinical trial. Crit Care. 2021 Jun 14;25(1):209. doi: 10.1186/s13054-021-03602-9.
Perez-Nieto OR, Escarraman-Martinez D, Guerrero-Gutierrez MA, et al. Awake prone positioning and oxygen therapy in patients with COVID-19: the APRONOX study. Eur Respir J. (2021) 2021:2100265. 10.1183/13993003.00265-2021
Ehrmann S, Li J, Ibarra-Estrada M, et al. Awake Prone Positioning Meta-Trial Group. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. Lancet Respir Med. 2021 Dec; 9(12): 1387–1395. doi: 10.1016/S2213-2600(21)00356-8.
Raoof S, Nava S, Carpati C, et al. High-flow, noninvasive ventilation and awake (nonintubation) proning in patients with coronavirus disease 2019 with respiratory failure. Chest. 2020;158(5):1992-2002. doi: 10.1016/j.chest.2020.07.013
