The use of corticosteroids in patients with pneumonia secondary to COVID-19 has been a controversially hot topic, particularly early on in the pandemic. Prior evidence seen in Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome have led some to argue against their use due to delayed viral clearance.1 More recent evidence related to SARS-Cov-2 has specifically shown reduced mortality and reduced need for mechanical ventilation with corticosteroids.2-4 More recently, the RECOVERY Trial showed an improvement in 28-day mortality among patients on oxygen therapy who received Dexamethasone.5 Little information exists in the literature about patients with moderate to severe disease who do not warrant ICU level of care but require hospital admission due to the extent of their illness. The authors of this study designed and conducted a pragmatic, partially randomized control trial to evaluate the possible benefit of methylprednisolone in hospitalized patients with moderate to severe COVID-19 pneumonia.
Background: Though oxygen is fundamental for life, supra-physiological levels can be deleterious. Several randomized controlled trials and meta-analyses have been conducted in the critically ill to determine whether a conservative oxygenation approach compared to a liberal oxygenation approach is beneficial. The OXYGEN-ICU trial was one of the first trials to explore this issue in 2016. It was a small, single centered trial with 434 ICU patients that showed a significantly lower ICU mortality in the conservative oxygenation group with an ARR 8.6%1. ICU-ROX (Mechanically ventilated patients) and LOCO2 (ARDS patients) were two more randomized trials that explored critically ill patients in the ICU with conflicting evidence on oxygen targets. There was no mortality benefit or ventilator free days in either study2,3. Although in the LOCO2 trial there was a clinically relevant excess mortality in the conservative group of 14 percentage points higher than in the liberal group at 90 days (not statistically significant) Additionally, the LOCO2 trial found a higher rate of intestinal ischemia in patients with a conservative oxygenation strategy3. Based on these three trials it can be stated that both hyperoxia (SpO2 >97%) and hypoxemia (SpO2 <90%) should be avoided. An SpO2 of 92 to 96% (PaO2 60 to 90) would be the ideal target in these patients. Until now, there has not been any good data regarding oxygenation parameters in patients with acute hypoxemic respiratory failure....Read More
Background: It has well been established that low tidal volume ventilation minimizes potentially iatrogenic harms of mechanical ventilation. What is less clear is the use of higher positive end expiratory pressure (PEEP) in patients without acute respiratory distress syndrome (ARDS). Use of PEEP helps prevent alveolar collapse and maintains recruitment of atelectatic and diseased alveoli. This improves the distribution of lung aeration over a more homogenously inflated lung surface which in turn may improve oxygenation. Although PEEP reduces cyclical opening and closing of alveoli during ventilation, a higher PEEP could also lead to new lung injury (ventilator-induced lung injury), impair hemodynamics (reducing venous return) and could delay weaning/extubation....Read More
Background: Facilities around the world have seen surges of COVID-19 pneumonia patients who have required protracted hospitalizations leading to overwhelmed hospital systems. Awake proning is a practice that was adopted early in the pandemic as a means to avoid, or at least delay, endotracheal intubation to lessen the burden of ICU care. Proning helps improve lung recruitment, reduce ventilation/perfusion mismatch, and reduces alveolar strain in intubated patients. Numerous small trials and anecdotes of awake proning have shown improvements in oxygenation and respiratory rate.However, whether these surrogate physiological endpoint improvements translate to better clinical outcomes (i.e. intubation and mortality) is still largely unknown....Read More