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 Table of Contents  
LETTER TO THE EDITOR
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 46-49

Early extubation to preventive noninvasive ventilation in coronavirus disease-2019 patient: A promising approach!


Department of Anaesthesia, Hamdard Institute of Medical Sciences and Research, New Delhi, India

Date of Submission10-Jan-2022
Date of Decision09-Feb-2022
Date of Acceptance15-Mar-2022
Date of Web Publication20-May-2022

Correspondence Address:
Dr. Jyotsna Agarwal
N-9, Green Park (Main), New Delhi - 110 016
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jica.jica_3_22

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How to cite this article:
Agarwal J, Panjiar P, Khanuja S, Hussain SY. Early extubation to preventive noninvasive ventilation in coronavirus disease-2019 patient: A promising approach!. J Ind Coll Anesth 2022;1:46-9

How to cite this URL:
Agarwal J, Panjiar P, Khanuja S, Hussain SY. Early extubation to preventive noninvasive ventilation in coronavirus disease-2019 patient: A promising approach!. J Ind Coll Anesth [serial online] 2022 [cited 2022 Jul 1];1:46-9. Available from: https://www.jicajournal.in//text.asp?2022/1/1/46/345598

Dear Sir,

Extensive literature is found on airway management, invasive and noninvasive ventilation (NIV) in coronavirus disease-2019 (COVID-19) patients.[1] However, specific data on extubation strategy in these patients are scarce. Some studies do suggest extubation protocol in COVID-19 patients to be similar to routine acute respiratory distress syndrome (ARDS) protocol.[2]

Lung pathology and clinical course in COVID-19 are different from typical ARDS. COVID-19 patients frequently require long periods of noninvasive and invasive ventilation.[3],[4] Traditional strategies of weaning from ventilators involving spontaneous breathing trials (SBTs) at low pressure support ventilation (PSV) may delay liberation from invasive ventilation in these patients.[3]

We report successful weaning of a COVID-19 patient from invasive ventilation to preventive NIV, with SBT at high-pressure support.

A 51-year-old male patient, weight – 80 kg and height – 172 cm, was admitted with COVID-19 pneumonitis in April 2021 on oxygen by face mask at 5 L/min and SpO2 – 92%. His oxygen demand escalated, and he was shifted to a nonrebreathing mask (NRBM) followed by NIV at PSV – 16 cmH2O. Positive end-expiratory pressure (PEEP) – 8 cmH2O and the fraction of inspired oxygen (FiO2) – 0.8. Sequential organ failure assessment (SOFA) score at intensive care unit (ICU) admission was 4.

Endotracheal intubation was done on the 15th day of hospital admission and ICU day 1, following the deterioration in arterial blood gas (ABG) and consciousness [Table 1]. This was done at the earliest when intubation criteria were met [Table 2].
Table 1: Patient arterial blood gas and investigations before and after intubation and extubation

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Table 2: Intubation and extubation criteria in our intensive care unit in coronavirus disease 2019 patients

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Initial ventilator settings were assist control ventilation (ACV) with FiO2 – 0.6, tidal volume (TV) – 450 mL, respiratory rate (RR) – 22/min, PEEP – 7 mmHg, plateau pressure – 18 cmH2O, driving pressure – 11 cmH2O, and static lung compliance – 39 mL/cmH2O. The patient was deeply sedated (Richmond Agitation Sedation Scale: −5) and paralyzed with prone ventilation for 16 h out of every 24 h. The patient's ventilation, ABG, and X-ray chest showed improvement on mechanical ventilation.

Weaning was attempted from ACV to PSV mode. At invasive PSV – 16 cmH2O, PEEP – 8 cmH2O, and FiO2 – 0.5, further weaning was not done. On confirmation of adequate consciousness and ventilation, the trachea was extubated. The total duration of endotracheal intubation and mechanical ventilation was 102 h. The patient was put on NIV at PSV – 18 cmH2O, PEEP – 8 cmH2O, with a FiO2 – 0.6. TV of 400–450 mL with an RR 25–28/min was generated on spontaneous ventilation. Dexmedetomidine infusion at 0.5 μg/kg/min was administered during invasive ventilation, which was stopped at extubation.

Patient's preextubation and postextubation vitals, Glasgow coma scale, ABG, investigations, and chest imaging are mentioned in [Table 1] and [Figure 1].
Figure 1: X-ray images of the patient. (a) Just after intubation, (b) At 72 h postintubation

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The patient had minimal secretions. He was on injectable empirical antibiotics to cover Gram-positive and -negative and anaerobic bacteria. Injection dexamethasone 8 mg BD and injection clexane 0.6 mg OD were ongoing. Remdesivir, tocilizumab, and plasma therapy were not administered to the patient during his entire course of illness.

The postextubation course showed progressive respiratory and systemic improvement. Three days after extubation, the patient developed mild pneumothorax, pneumomediastinum, and subcutaneous emphysema, without any associated clinical deterioration. NIV settings were PSV – 14 cmH2O, PEEP – 8 cmH2O, and FiO2 – 0.6. The above-mentioned clinical features resolved spontaneously upon weaning from NIV to NRBM. Over a period of the next 10 days, the patient was further weaned from NRBM to face mask at an oxygen flow of 5–6 L/min. Fifteen days after extubation, based on the COVID reverse transcriptase–polymerase chain reaction negative report, he was shifted to non-COVID ICU for further management. Written informed consent was obtained from patient and his next of kin for the preparation and publication of this report.

Longer periods of tracheal intubation in COVID-19 patients pose a high risk of postextubation respiratory failure. Higher degree of extubation readiness such as SBT at lower PSV parameters (≤5 cmH2O), SBT at the very end of weaning process or longer periods of SBT (for 2–4 h) are suggested by some authors, in these patients.[3],[4]

What was different in our approach

We gave SBT at invasive PSV with high-pressure support (16 cmH2O) and PEEP (8 cmH2O). Trachea was extubated even when the extubation criteria of our ICU were not entirely met [Table 2]. The PaO2 was <60 mmHg at FiO2 of 0.5 and SBT was given at high pressure support. The decision to extubate was based on improvement in underlying disease. This was confirmed by improvement in X-ray chest, blood counts, ventilatory parameters, and consciousness. It is possible that lung infection led to deterioration in clinical condition leading to tracheal intubation. The infection resolved with antibiotics over 4 days, and clinical improvement was seen. However, the endotracheal culture after intubation, blood culture and urine culture sent during these 4 days did not grow any pathogenic organisms. It was anticipated that with improving lung condition, the patient should maintain adequate spontaneous ventilation at NIV with settings similar to invasive PSV. Slightly higher pressure support, PEEP, and FiO2 were set on NIV initially, to reduce the work of breathing. Explained consent was taken from patients next of kin, equipment for intubation was kept ready and threshold for reintubation was kept low.

We feel that successful early extubation to preventive NIV in our patient was made feasible by various factors. Our patient had no evidence of progressive systemic infection, hemodynamic instability, or multiorgan involvement at the time of weaning. Early intubation, effective sedation, and paralysis, low TVs with optimal PEEP (8–10 cmH2O) helped in preventing further lung damage. Fluid overload, cardiac output demand, and patient self-induced lung injury were avoided early and effectively. There was minimal sputum production and retention. The primary disease did not progress further. This was evident with improvement in clinical picture, lung imaging, and laboratory reports.

ATS/CHEST guidelines in ARDS patients recommend early extubation to preventive NIV in patients at high risk for extubation failure who have been receiving mechanical ventilation for more than 24 h and who have passed an SBT.[5]

Gamberini et al. reported an average duration of 10–18 days of mechanical ventilation in COVID-19 patients, with 10% of the patients having failed extubation within 48 h. Independent risk factors for prolonged ventilation found in this study were increasing age, high SOFA score at ICU admission, low PaO2/FiO2 ratio, low static respiratory system compliance in initial 5 days of mechanical ventilation, need for renal replacement therapy, late-onset ventilator-associated pneumonia, and cardiovascular complications during ICU stay.[6] Of these, our patient had only two factors, which were low static lung compliance and low PaO2/FiO2 before intubation.

Zhang et al. reported early extubation at 4 and 11 days in two COVID-19 patients, followed by oxygenation through a high flow nasal cannula (HFNC). Both patients required reintubation within 120 h due to continued progression of primary disease and inadequate sputum drainage.[7] HFNC was not applied in our patient.

A wide range of complications can be avoided by early weaning from mechanical ventilation such as ventilator-associated pneumonia, lung injury, and ventilator dependence, to name a few. Further studies on a larger number of patients are warranted for establishing the usefulness of this extubation strategy in COVID-19 patients.

Early weaning from mechanical ventilation in select COVID-19 patients can be attempted by extubating to preventive NIV at high PSV.

In the face of varied clinical presentation of COVID-19, a rational approach should be instituted while following traditional ARDS ventilatory protocols. Individual assessment of COVID-19 patients requiring mechanical ventilation is required to identify patients, who may benefit from early extubation strategy.

Consent

This case report was published with the written consent of the patient and next of kin.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient and the next to kin have given his consent for images and other clinical information to be reported in the journal. The patient and the next to kin understand that names and initials will not be published, and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Patwa A, Shah A, Garg R, Divatia JV, Kundra P, Doctor JR, et al. All India difficult airway association (AIDAA) consensus guidelines for airway management in the operating room during the COVID-19 pandemic. Indian J Anaesth 2020;64:S107-15.  Back to cited text no. 1
    
2.
Grasselli G, Cattaneo E, Florio G, Ippolito M, Zanella A, Cortegiani A, et al. Mechanical ventilation parameters in critically ill COVID-19 patients: A scoping review. Critical Care 2021;25:115.  Back to cited text no. 2
    
3.
Marini JJ, Gattinoni L. Management of COVID-19 respiratory distress. JAMA 2020;323:2329-30.  Back to cited text no. 3
    
4.
Anesi GL. COVID-19: Management of the intubated adult. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2020. Available from: https://www.uptodate.com/contents/covid-19-management-of-the-intubated-adult. [Last accessed on 2022 Apr 25].  Back to cited text no. 4
    
5.
Schmidt GA, Girard TD, Kress JP, Morris PE, Ouellette DR, Alhazzani W, et al. Official executive summary of an American Thoracic Society/American College of Chest Physicians clinical practice guideline: Liberation from mechanical ventilation in critically ill adults. Am J Respir Crit Care Med 2017;195:115-9.  Back to cited text no. 5
    
6.
Gamberini L, Tonetti T, Spadaro S, Zani G, Mazzoli CA, Capozzi C, et al. Factors influencing liberation from mechanical ventilation in coronavirus disease 2019: Multicenter observational study in fifteen Italian ICUs. J Intensive Care 2020;8:80.  Back to cited text no. 6
    
7.
Zhang J, He X, Hu J, Li T. Failure of early extubation among cases of coronavirus disease-19 respiratory failure: Case report and clinical experience. Medicine (Baltimore) 2020;99:e20843.  Back to cited text no. 7
    


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