COVID-19 care is draining. COVID-19 disease, caused by the SARS-CoV-2 virus, fatigues bodies and deflates airways of patients. The care shifts wear down minds, emotions and energy of healthcare workers as well as places them at risk for infection. The case volumes deplete supplies, equipment and capacities of hospitals and facilities.
Somehow, though, this critical care must forge on, even in dire times of patient deluge and virus variant evolution. To perform their essential jobs on the front lines, medical personnel and teams, however, need to be outfitted and equipped with the supplies they need for infection prevention and the machines they need to help patients breathe and live.
“When looking at the COVID-19 patient population admitted, the best practice should be comprised of highly skilled healthcare providers from several different disciplines, an advanced and well-equipped medical facility, advanced monitoring platforms, preferably such that can provide continuous remote patient monitoring with integrated automated early detection of deterioration and alert systems, and advanced oxygen supplement and diverse ventilation capabilities,” Eisenkraft said. “Surveillance closed-circuit cameras deployed in the contaminated treatment area help in monitoring patients in real time by personnel located outside the contaminated treatment zone.”
He continued, “Ideally, in order to provide high quality treatment and allow rapid response, there should be a healthcare provider on each COVID-19 patient. However, due to the large numbers of patients, and despite their complexity and multi-system injury, this is not possible. As time goes by, we see more and more medical staff suffering from burnout and exhaustion, as a result of numerous intensive shifts in the last year.”
Supporting staff safety, patient care
Comprehensive care during the COVID-19 pandemic, of course, has elevated concentration on infection control and supply accessibility.
He added, “The second is access to the appropriate equipment to provide the appropriate therapy. In early 2020, the focus was providing invasive ventilation to COVID-19 patients with hypoxemic respiratory failure, or insufficient oxygen in their blood. This focus drove the manufacture, stockpile, and purchase of thousands of mechanical ventilators.”
A year ago, at the start of crisis in the United States, the “U.S. Food and Drug Administration took significant action to help increase the availability of ventilators and accessories, as well as other respiratory devices, during the COVID-19 pandemic to support patients with respiratory failure or difficulty breathing,” according to a press release from the agency. 1
The FDA continued, “First, the guidance describes the agency’s intention to exercise enforcement discretion for certain modifications to these FDA-cleared devices. The guidance also helps manufacturers ramp up their manufacturing by adding production lines or alternative sites, for instance, using non-medical device manufacturers such as automobile manufacturers, to start manufacturing ventilator parts. Second, hospitals and healthcare professionals may use ventilators intended for other environments. The FDA also provides recommendations for other alternatives that should be considered such as devices for treating sleep apnea. The FDA’s policy also applies to health care facilities that use ventilators beyond their indicated shelf life, which should increase ventilator capacity. Finally, the agency encourages manufacturers, whether foreign or domestic, to talk to FDA about pursuing an emergency use authorization (EUA), which would allow them to distribute their ventilators in the United States.”1
Fast forward to today, ventilator and other medical supplies and equipment remain crucial to care.
“We have continued to support health care, and the pharmaceutical companies that are rapidly developing and manufacturing COVID-19 vaccines,” said Mattias Perjos, President & CEO, Getinge in a press release.2 He added, “We also achieved our full-year target of delivering 26,000 advanced ICU ventilators, and the demand for our ECMO therapy products remains high.”2
Noninvasive treatment is another method that may be provided in care for patients.
“From a clinical perspective, the initially high ventilator mortality rates led the refocus away from mechanical ventilation towards noninvasive therapies like Nasal High Flow (often described as the interface high flow nasal cannula, or HFNC) for COVID-19 patients,” Hutchinson explained. “The challenge for hospitals now is sourcing equipment to provide these new therapies. A study by Patel et al (2020) published in BMJ Open Respiratory Research Journal suggested that high flow nasal therapy use was associated with a reduction in the rate of mechanical ventilation and overall mortality in patients with COVID-19 infection. In this example, patients received therapy beginning around 35 L/min and were steadily increased up to 60 L/min to achieve the desired patient outcomes.”3
“As the patient population with COVID-19 continues to recover, it will be essential to monitor the long-term effects the disease may have had on their pulmonary lung function,” Gilberg said. “Because COVID-19 is a new disease, studies are ongoing to determine what these long-term effects may be and how spirometry may be able to help. Due to the number of Americans impacted by COVID-19, it will be essential for physicians at the primary care level to monitor their patient’s recovery. Yet, prior to COVID-19, 47 percent of primary care physicians reported not having a spirometry device within their clinic.”4
Enhancing airways, breathing
When they go to hospitals, patients with COVID-19 often arrive in extreme and fragile conditions. Consequently, they require special movement and care.
One research-based practice that may help improve breathing for patients who receive ventilation treatment is proning.
“Proning is now considered the standard for treating COVID patients in respiratory distress,” Gassman indicated. “As more data has become available, peer-reviewed evidence has emerged that supports proning as a part of COVID-19 protocols for ventilated patients. Proning is the process of turning patients onto their stomachs for extended periods of time. Up to this point, hospitals have justified proning COVID-19 patients based on established treatments for other respiratory diseases such as Acute Respiratory Distress Syndrome (ARDS). For patients with ARDS, the prone position is used in an attempt to improve oxygenation and reduce ventilator-induced lung injury, according to the American Association of Colleges of Nursing. We are hearing from healthcare providers that they are seeing improvement in oxygenation in COVID patients when practicing prolonged proning.5 Furthermore, providers are noting improvement when patients turn on their stomachs at home.”
She noted, “The process can be done manually or by using a patient lift. Lifts and friction-reducing devices can help reduce the amount of physical exertion required by staff to perform the task.”
Eisenkraft adds that proning is performed by several healthcare providers and may help decrease the risks of complications or ventilation.
“The prone position allows for better expansion of the back regions of the lungs, helping to enhance removal of secretions,” he explained. “This, in turn, leads to improved breathing and oxygenation. In many cases, this improvement is vital in preventing patients experiencing mild respiratory distress from deteriorating, avoiding being ventilated or progressing to severe respiratory distress.”
Proning additionally may be helpful for patients receiving Nasal High Flow therapy, says Hutchinson.
“Anecdotally, initial clinical evidence to date has suggested that early prone positioning with Nasal High Flow may reduce the number of COVID-19 patients escalating to severe or critical status.”
Preventing injuries, infections
Care for COVID-19 patients encompasses proper positioning and handling along with continuous care and monitoring for safety.
“Patients placed in the prone position can be in this position for 12 or more hours,” Gassman said. “Patients in the critical care unit are also at a higher risk of developing pressure injuries due to the severity of their illness, immobility, mechanical ventilation and infrequent repositioning. To prevent pressure injury while patients are in this position, it is important to perform routine skin assessments and off load and pad bony prominence areas.”
She recommends tactics to help reduce the risk of pressure injuries in patients in the prone position, including:
- Reposition patient every two to four hours.
- Turn head and alternate raising arms in a swimming position.
- Use wedges or pillow to off load bony prominences.
- Keep the patient’s body in good spinal alignment to reduce risk of muscle strain and contractures.
- Routinely check skin around medical devices, securement devices and tubing to prevent pressure injuries and rotate devices and securement sites to redistribute pressure. Be aware that edema under devices have a potential for skin breakdown. Also, make sure to document all skin assessments and preventive measures.
- Position in reverse Trendelenburg to reduce optical pressure and swelling.
- Use dressings as prevention for injury. Moisture can be managed with dry pads, liquid protectants/sealants, and absorbent dressing such as foam dressing, hydrofiber/calcium alginate.
- It is also important to assess adequate nutrition.
- When using any type of equipment or products, such as beds, positioning devices, and dressings, make sure to follow manufacturer instructions.”
COVID-19 infection, as found, may cause other serious complications and long-term health effects.
“COVID-19 patients show multi-system injuries, with cardio-pulmonary involvement being the most prevalent,” Eisenkraft explained. “The pulmonary injury damages the ability to properly oxygenate, often leading to rapid and unexpected deterioration. There is more and more evidence that the cardiac injury also has an important role. This makes these patients complex and unpredictable, and when adding the fear of exposure and infection, treatment is highly challenging.”
He added, “It is not often that we encounter a situation in which improper handling of ventilation equipment might lead to environmental contamination with the potential of infecting healthcare providers. Moreover, these complex patients require intense handling by medical staff with continuous monitoring, to allow timely alerts if and when they deteriorate. Most devices used for monitoring COVID-19 patients do not provide all the necessary vitals, and respiratory monitoring is only partially achieved.”
Tracking vital signs and functions is important throughout care.
“Measuring and adjusting cuff pressure is critical for patients intubated with a cuffed endotracheal (ET) tube, trach tube, or laryngeal mask airway (LMA), but cuff pressures can change rapidly, especially during transport or as patients change position, such as proning,” Gassman emphasized. “In the U.S. market, Medline is now an exclusive distributor of Hospitech Respiration Ltd.’s AG Cuffill, a device that enhances patient safety while diminishing the risk of cross contamination.6 AG Cuffill allows clinicians to make monitoring cuff pressure a standard of care while reducing the risks and costs associated with pressures above or below the recommended range. The Cuffill can be used by various care providers, including respiratory, anesthesia, first responders and home providers, to reduce potential for aspirations with an under-inflated cuff or ischemic injury that can result from over-inflation.”
Patients, post-recovery, may need additional ongoing monitoring and treatment.
“Pulmonary function testing with a spirometer is used to measure a patient’s lung function and identify abnormal lung function,” Gilberg stated. “Spirometer test results rely heavily on the patient effort. To best support the patient’s effort, it is essential for the technician to set proper expectations and coach properly throughout the maneuver. Many patients have never performed a spirometry test, so demonstrating proper position and testing technique is beneficial. The technician can also encourage the patient to continue blowing as hard and as fast as they can.”
Gilberg adds that the spirometer process and protocols include:
- Patients need to ensure they are seated, with their shoulders back and chin up. They should also use a nose clip to ensure all air capacity from their lungs is being exhaled through the mouth.
- Clinics should calibrate their device daily, prior to use, with a 3L calibration syringe according to ATS guidelines.7 This ensures the device is performing accurately before any tests are completed.
- Follow CDC and ATS guidelines on the proper PPE to use and environment disinfecting processes.
- Mouthpieces are single use and should be replaced between each patient.
- The Midmark spirometer has a unique eject lever to avoid handling of the mouthpiece, reducing risk of cross contamination.”
Making strides with practices
As COVID-19 persists and evolves, healthcare agencies and providers move forward to adapt care and improve outcomes for patients.
“Since the first signs of COVID-19 in early 2020, treatment guidelines from numerous national and international societies have been published including ATS, ACEP, SSC, DoD, NIH, AARC and ANZICS to name a few,” Hutchinson noted. “Each of these treatment guidelines favor the use of Nasal High Flow over other noninvasive therapies because of patient tolerance, increased efficacy, and lower mortality. In addition, one notable clinical practice guideline published by Rochwerg et al (2020)8 described the role of high flow nasal cannula as a respiratory support strategy.”
He shares two published examples of positive results of Nasal High Flow therapy, including:
- Jackson (2020) described UnityPoint Health in Des Moines, IA, where at the time of writing, 116 of 321 (36 percent) of hospitalized COVID-19 patients required escalation of care due to acute hypoxemic respiratory failure and 96 (83 percent) received Nasal High Flow as respiratory support. Of the 70 patients discharged at the time of writing, 49 (70 percent) did not require mechanical ventilation.9
- Patel (2020) described Temple University Hospital in Philadelphia, PA, where at the time of writing, 67 of 104 (64 percent) of moderate-to-severe respiratory failure COVID-19 patients on Nasal High Flow avoided escalation to noninvasive ventilation or invasive ventilation.10”
With regard to new treatment testing, The National Institutes of Health reported that, “Early data from a clinical study suggest that blocking the Bruton tyrosine kinase (BTK) protein provided clinical benefit to a small group of patients with severe COVID-19. Researchers observed that the off-label use of the cancer drug acalabrutinib, a BTK inhibitor that is approved to treat several blood cancers, was associated with reduced respiratory distress and a reduction in the overactive immune response in most of the treated patients. In some patients with severe COVID-19, a large amount of cytokines is released in the body all at once, causing the immune system to damage the function of organs such as the lungs, in addition to attacking the infection. This dangerous hyperinflammatory state is known as a ‘cytokine storm.’ At present, there are no proven treatment strategies for this phase of the illness.”11
In terms of updated guidance for hospital and at-home care, “WHO recommends that patients who have COVID-19 – both confirmed and suspected – should have access to follow-up care if they have persistent, new or changing symptoms. This is one of the recommendations made by WHO in revised clinical management guidelines. Evidence was gathered on the post-COVID condition, so-called ‘long COVID,’ where people who have recovered from COVID-19 continue to have longer-term issues like extreme fatigue, persistent cough and exercise intolerance.”12
WHO continued, “For COVID-19 patients at home, WHO suggests the use of pulse oximetry to measure oxygen levels in the blood. This needs to be coordinated with other aspects of home care, such as education for the patient and care provider and regular follow-up of the patient. For hospitalized patients, WHO suggests the use of low dose anticoagulants for preventing the blood clots forming in blood vessels (thrombosis). For hospitalized patients who are taking supplemental oxygen (including high-flow nasal oxygen) or non-invasive ventilation, WHO suggests positioning patients on their stomachs to increase oxygen flow (awake prone positioning).”12
Eisenkraft additionally points to achievements with automated monitoring technology.
“When Biobeat deployed its systems – wireless, wearable, non-invasive, continuous remote patient monitoring sensors and web application – to manage the patients all across Israel, we were asked about providing an early warning score (EWS),” he explained. “We saw the currently used score, in which healthcare personnel had to fill manually the vitals and calculate the score, performing that once a shift. Within one week we integrated an automated EWS system into our platform, allowing them to get the updated score automatically every five minutes, helping to prevent patient deterioration. We were approached by many healthcare providers, telling us that our platform helped them as an important decision support tool with difficult choices, such as whether to ventilate a patient or not, as well as deciding on the discharge of patients.”
References:
1. Coronavirus (COVID-19) Update: FDA Continues to Facilitate Access to Crucial Medical Products, Including Ventilators, For Immediate Release: March 22, 2020, https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-continues-facilitate-access-crucial-medical-products-including
2. Press release Gothenburg, Sweden on January 28, 2021 Getinge Full Year Report 2020: Intense efforts to support health care and pharmaceutical companies, https://mb.cision.com/Public/942/3274989/b022cec7a9dd7132.pdf
3. Non-invasive ventilation, Retrospective analysis of high flow nasal therapy in COVID-19-related moderate-to-severe hypoxaemic respiratory failure, Maulin Patel, Andrew Gangemi, Robert Marron, Junad Chowdhury, Ibraheem Yousef, Matthew Zheng, Nicole Mills, Lauren Tragesser, Julie Giurintano, Rohit Gupta, Matthew Gordon, Parth Rali, Gilbert D’Alonso, David Fleece, Huaqing Zhao, Nicole Patlakh and Gerard Criner, https://bmjopenrespres.bmj.com/content/7/1/e000650
4. CHEST Journal, Editorials | Volume 129, Issue 4, P833-835, APRIL 01, 2006, Does Screening for COPD by Primary Care Physicians Have the Potential to Cause More Harm than Good, Enright Paul, MD, DOI: https://doi.org/10.1378/chest.129.4.833
5. Prone Positioning in Severe Acute Respiratory Distress Syndrome, Claude Guérin, M.D., Ph.D., Jean Reignier, M.D., Ph.D., Jean-Christophe Richard, M.D., Ph.D., Pascal Beuret, M.D., Arnaud Gacouin, M.D., Thierry Boulain, M.D., Emmanuelle Mercier, M.D., Michel Badet, M.D., Alain Mercat, M.D., Ph.D., Olivier Baudin, M.D., Marc Clavel, M.D., Delphine Chatellier, M.D., et al., for the PROSEVA Study Group, https://www.nejm.org/doi/full/10.1056/NEJMoa1214103
6. Medline Expands Respiratory Care Portfolio, Medline and Hospitech Respiration Ltd. join forces to extend reach of disposable cuff pressure management device, September 9, 2020, https://newsroom.medline.com/releases/medline-expands-respiratory-care-portfolio
7. ATS Journals, Standardization of Spirometry 2019 Update. An Official American Thoracic Society and European Respiratory Society Technical Statement, Brian L. Graham , Irene Steenbruggen , Martin R. Miller , Igor Z. Barjaktarevic , Brendan G. Cooper , Graham L. Hall , Teal S. Hallstrand , David A. Kaminsky , Kevin McCarthy , Meredith C. McCormack , Cristine E. Oropez , Margaret Rosenfeld , Sanja Stanojevic , Maureen P. Swanney, and Bruce R. Thompson ; on behalf of the American Thoracic Society and the European Respiratory Society, https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1590ST#_i12
8. Conference Reports and Expert Panel, Published: 17 November 2020, The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline, Bram Rochwerg, Sharon Einav, Karen E. A. Burns
9. High Flow Nasal Cannula for Acute Hypoxic Respiratory Failure in COVID-19, Julie A Jackson, Matthew W Trump, Trevor W Oetting, Sarah K Spilman and Carlos A Pelaez, Respiratory Care October 2020, 65 (Suppl 10) 3448481;
10. Non-invasive ventilation, Retrospective analysis of high flow nasal therapy in COVID-19-related moderate-to-severe hypoxaemic respiratory failure, Maulin Patel, Andrew Gangemi, Robert Marron, Junad Chowdhury, Ibraheem Yousef, Matthew Zheng, Nicole Mills, Lauren Tragesser, Julie Giurintano, Rohit Gupta, Matthew Gordon, Parth Rali, Gilbert D’Alonso, David Fleece, Huaqing Zhao, Nicole Patlakh and Gerard Criner
11. Friday, June 5, 2020, Study identifies potential approach to treat severe respiratory distress in patients with COVID-19, https://www.nih.gov/news-events/news-releases/study-identifies-potential-approach-treat-severe-respiratory-distress-patients-covid-19
12. WHO recommends follow-up care, low-dose anticoagulants for COVID-19 patients, 26 January 2021, https://www.who.int/news-room/feature-stories/detail/who-recommends-follow-up-care-low-dose-anticoagulants-for-covid-19-patients
