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[COVID-19] CPAP use for Coronavirus mitigation & severe pneumonia
#21
RE: CPAP use for Coronavirus mitigation & severe pneumonia
(03-13-2020, 04:07 PM)SuperSleeper Wrote:
(03-13-2020, 03:28 PM)SarcasticDave94 Wrote: Tis a shame we don't know how to up the pressure...


That is the kind of statement or idea that might stimulate someone with a bit of knowledge on CPAP mechanics into thinking, "Wait a minute,  I think that actually might be possible".

We simply never know, folks.  Good comment, Dave.   Smile

Quote:National Academy of Medicine
Duty to Plan: Health Care, Crisis Standards of Care, and Novel Coronavirus SARS-CoV-2
https://nam.edu/duty-to-plan-health-care-crisis-standards-of-care-and-novel-coronavirus-sars-cov-2/

Critical Care for the COVID-19 Patient

Little is known about the optimal treatment of the COVID-19 patient at this time. Knowledge of other coronaviruses such as SARS and MERS suggests that supportive care is the mainstay of therapy [31]. Providers should be prepared for potential shortages of materials and medications due to supply chain disruption in other countries, including China, though the scope and impact are unpredictable. Remdesivir, an investigational antiviral that has activity against MERS-CoV in animal models and was used in human trials for Ebola, is being evaluated in a clinical trial [32]. Other HIV protease inhibitors could have efficacy based on potential binding to coronavirus protease, but actual benefit or harm in treating COVID-19 is unknown. Steroids have not been shown to be helpful in treating other coronaviruses and may prolong viral shedding [33,34,35].
Initial reports describe progression of lung injury in the second week of illness and severe cases may require prolonged treatment, including mechanical ventilation. Providers should be careful not to conflate failure to improve within days with a poor prognosis, as improvement can be very slow. Use of BiPAP or Continuous Positive Airway Pressure (CPAP) may forestall the need for intubation and has been broadly used in early case series and anecdotal reports [36].

Additional CPAP machines might be available from home users for use in hospital settings, and adjusted criteria for intubation and weaning may reduce days on a ventilator.

ECMO may provide effective treatment for refractory cases [36], but ECMO requires extensive resources and the number of patients that can be placed on ECMO is small. If hospitals are overwhelmed, there should be a regional decision-making process to determine if the resources allocated to ECMO could be better used for a larger group of patients [12]. Providers should be prepared to re-use items such as endotracheal tubes, nasogastric tubes, oxygen delivery masks and tubing, and even ventilator circuits with appropriate high-level disinfection and sterilization as appropriate.

Additional protocols may include:

  • Patients should wear simple flexible fabric masks to reduce droplet generation unless wearing an oxygen mask

  • Oxygen and oxygen administration supplies may need to be conserved—accepting lower oxygen saturations prior to initiating oxygen may be required

  • Intermittent rather than continuous oximetry and cardiac monitoring may be instituted

  • Use inhalers in lieu of nebulized medications to reduce droplet generation

  • Coordinate with critical care physicians regarding threshold for intubation and use of bridging techniques (e.g., high flow cannula/BiPAP), which may require a special area and augmented PPE (e.g., PAPR) for providers given the higher risk of aerosol generation

  • Use rapid sequence intubation (RSI) techniques during intubation to minimize aerosol generation

  • Aggressively control and suppress patient cough, as possible

  • Reduce suctioning as possible

  • Use of High Efficiency Particulate Air (HEPA) filters on ventilators or at minimum in-line HME/HEPA filters on the endotracheal tube

  • Consider more aggressive sedation/paralysis strategies to reduce coughing, as applicable

  • Monitor the literature to determine potential efficacy of anti-virals (there is currently no known effective medications and limited evidence for bacterial super-infection) and other therapies

  • Monitor the literature for prognostic information that may inform resource triage decisions if necessary. Expect a prolonged course of mechanical ventilation [35]; therefore, “trial periods” of a few days are not recommended as improvement may not occur for days or even weeks. Sequential Organ Failure Assessment scores have limited prognostic value in viral-induced lung injury compared to sepsis so they should be used as contributory data and not to exclude a patient from resources [10,11,37,38].
[36] Wang, D., B. Hu, C. Hu, F. Zhu, X. Liu, J. Zhang, B. Wang, H. Xiang, Z. Cheng, Y. Xiong, Y. Zhao, Y. Li, X. Wang, and Z. Peng. 2020. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA.
https://jamanetwork.com/journals/jama/fu...le/2761044
"The object in life is not to be on the side of the majority, but to escape finding oneself in the ranks of the insane." -- Marcus Aurelius
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#22
RE: CPAP use for Coronavirus mitigation & severe pneumonia
Good find, srlevine1. Well-done

Looks like we're not the first ones to think of this possible usage for CPAP. Happy Eyes
SuperSleeper
Apnea Board Administrator
www.ApneaBoard.com


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.




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#23
RE: CPAP use for Coronavirus mitigation & severe pneumonia
For me, the utility of CPAP/APAP in this scenario will depend to some extent on how the symptoms manifest. I know that, whenever I have a cold or the 'flu, I find it really hard to use CPAP, because the congestion inhibits the free movement of air through my nose and mouth.

So, if throat and nasal congestion is a feature of C-19, I'm in trouble. If the clogging is confined to the lungs then ... maybe.

I guess the people who could best chip in here are those who have used PAP while suffering a lower respiratory infection, to let us know how they fared (other than surviving).
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#24
RE: CPAP use for Coronavirus mitigation & severe pneumonia
N = 1 here.
I was having a bad flare of asthma and the AHI zoomed. I checked with my provider and there did not appear to be any guidelines for adjusting the pressure under that circumstance. Tested doubling of the pressure which lowered the AHI somewhat and thus seemed helpful. (While I have a ResMed auto, the sleep testing indicated that alllowing a pressure above 9 actually worsened the AHI.)

To the extent difficulty breathing is one of the major symptoms, use of a CPAP, BiPAP, or ASV may be at least partially useful in managing potentially scarce resources.
                                                                                                                          
Note: I'm an epidemiologist, not a medical provider. 
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#25
RE: CPAP use for Coronavirus mitigation & severe pneumonia
For us here at AB, it might be a bit trickier because we are fighting both apneas and being able to breathe.

For someone without a sleep disorder, xPAP might work out better. I don’t know, hopefully some air is better than none.

John
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#26
RE: CPAP use for Coronavirus mitigation & severe pneumonia
So, to move the conversation along here...

The scenario:

So, let's assume that the manure has hit the fan, and hospitals are completely overwhelmed and unable to treat additional coronavirus patients.

Here we are at home, with what seems to be the start of a case of severe pneumonia, and we're completely on our own...

On a practical basis, assuming a CPAP, Bi-Level or ASV is all we have at home to help with some degree of ventilation, what settings could be changed to help in this regard?

On a CPAP, could we simply up the pressure to 20 with a setting of 3 on C-Flex, A-Flex or EPR to provide exhalation relief?

Or a Bi-Level, up the pressure to 25, with the maximum amount of pressure support & flex/EPR as well?

Or on an ASV, go to the max pressure and make similar adjustments to the "comfort" settings?

Again, what pros or cons would there be to such a strategy?  On one hand, the higher pressure might increase our AHI, especially with pressure-induced centrals.  On the other hand, if we don't get as high of ventilation as possible, we could die from pneumonia.

Are there ways in which we can provide increased pressure for ventilation purposes or does that become too risky for someone who already has sleep apnea?

(Again, we're assuming a worst-case scenario where conventional medical facilities and treatments are no longer available to us and there is a real risk that we might die of pneumonia).

Ideas or thoughts?  Thinking-about
SuperSleeper
Apnea Board Administrator
www.ApneaBoard.com


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.




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#27
RE: CPAP use for Coronavirus mitigation & severe pneumonia
(03-14-2020, 08:46 PM)SuperSleeper Wrote: So, to move the conversation along here...

The scenario:

So, let's assume that the manure has hit the fan, and hospitals are completely overwhelmed and unable to treat additional coronavirus patients.

Here we are at home, with what seems to be the start of a case of severe pneumonia, and we're completely on our own...

On a practical basis, assuming a CPAP, Bi-Level or ASV is all we have at home to help with some degree of ventilation, what settings could be changed to help in this regard?

On a CPAP, could we simply up the pressure to 20 with a setting of 3 on C-Flex, A-Flex or EPR to provide exhalation relief?

Or a Bi-Level, up the pressure to 25, with the maximum amount of pressure support & flex/EPR as well?

Or on an ASV, go to the max pressure and make similar adjustments to the "comfort" settings?

Again, what pros or cons would there be to such a strategy?  On one hand, the higher pressure might increase our AHI, especially with pressure-induced centrals.  On the other hand, if we don't get as high of ventilation as possible, we could die from pneumonia.

Are there ways in which we can provide increased pressure for ventilation purposes or does that become too risky for someone who already has sleep apnea?

(Again, we're assuming a worst-case scenario where conventional medical facilities and treatments are no longer available to us and there is a real risk that we might die of pneumonia).

Ideas or thoughts?  Thinking-about

It appears to me that the sole purpose of all of the xPap devices is to ensure an adequate supply of air during sleep. 

Which begs the question, what happens to those on supplemental oxygen being fed into the xPap device either using the hose nipple or directly into the mask? And, what is the effect of additional ventilation or oxygen on an "emerging" virus infection? 

In short, while we are making our breathing and sleeping easier, what is happening to the infection? Do we up the settings at the first signs of potential difficulty or do we wait for a doctor's suggestion -- although it may be unlikely that a general practitioner will have specific knowledge relating to the use of xPap devices in this manner.
"The object in life is not to be on the side of the majority, but to escape finding oneself in the ranks of the insane." -- Marcus Aurelius
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#28
RE: CPAP use for Coronavirus mitigation & severe pneumonia
The closest I can come to advice comes from the World Health Organization and it is contained in "Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected Interim guidance 13 March 2020"

It appears that a thermometer and a pulse-oximeter may be your new best friends.

Quote:5. Management of severe COVID-19: oxygen therapy and monitoring

Give supplemental oxygen therapy immediately to patients with SARI and respiratory distress, hypoxaemia or shock and target SpO2 > 94%.

Remarks for adults: Adults with emergency signs (obstructed or absent breathing, severe respiratory distress, central cyanosis, shock, coma, or convulsions) should receive airway management and oxygen therapy during resuscitation to target SpO2 ≥ 94%. Initiate oxygen therapy at 5 L/min and titrate flow rates to reach target SpO2 ≥ 93% during resuscitation; or use face mask with reservoir bag (at 10–15 L/min) if patient in critical condition. Once patient is stable, the target is > 90% SpO2 in non-pregnant adults and ≥ 92–95% in pregnant patients (16, 25).

Remarks for children: Children with emergency signs (obstructed or absent breathing, severe respiratory distress, central cyanosis, shock, coma or convulsions) should receive airway management and oxygen therapy during resuscitation to target SpO2 ≥ 94%; otherwise, the target SpO2 is ≥ 90% (25). Use of nasal prongs or nasal cannula is preferred in young children, as they may be better tolerated.

Remark 3: All areas where patients with SARI are cared for should be equipped with pulse oximeters, functioning oxygen systems and disposable, single-use, oxygen-delivering interfaces (nasal cannula, nasal prongs, simple face mask, and mask with reservoir bag). See Appendix for details of resources.
"The object in life is not to be on the side of the majority, but to escape finding oneself in the ranks of the insane." -- Marcus Aurelius
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#29
RE: CPAP use for Coronavirus mitigation & severe pneumonia
There are many problems associated with simply setting these devices on maximum pressure. While they may make tolerating flue symptoms, they cannot provide treatment for pneumonia. You can push all the pressure you want into an inflmmed, fluid filled lung, and not create air-exchange at the alveolar level. To imply otherwise is at best misleading, and potentially dangerous advise. For sub-acute care, there may be increased comfort with positive pressure and especially bilevel pressure, but if infection and fluid impairs lung volume, you will not survive home treatment.

In the case of CPAP, pressure should be increased until it is comfortable, but not beyond that threshold. Side-effects include leaks, aerophagia and discomfort exhaling into high pressure. There is no advantage to using higher pressure than you tolerate comfortably.

Bilevel is more complicated. Without a backup rate as in ST or ASV, most of us will experience central apnea events. Give it a try if you don't believe me. above 6 or 7 cm of pressure support you might feel respiration is amazingly easy, but you won't tolerate it long after your CO2 drops enough to trigger your apneic threshold. https://joof urnals.lww.com/jcejournal/abstract/1978/10000/the_measurement_of_apneic_threshold_in.12.aspx There is an appropriate and comfortable level of pressure and pressure support that may provide more relief, and exceed ing that will do more harm than good.

With ASV a higher minimum EPAP and minimum pressure support may help, but in auto mode the machines target minute vent or tidal volume and should continue to provide effective therapy and perhaps relief from congestion. The ST can be set to provide static EPAP and IPAP pressure, and like bilevel may exceed the apneic threshold. Most people are not prepared to use enough pressure support (8 to 12 cm) to overcome the central apnea, so your could do more harm than good. AVAPS or iVAPS is the most appropriate ventilator to maintain alveolar volume, but the problem with pneumonia is that fluid in the lungs must be eliminated or there simply no volume to fill with air.

CPAPs, bilevels and non-invasive ventilators are not intended nor shown to be effective for treatment of pneumonia. I really don't thing Apnea Board should promote any fantasy that they might be suitable for this purpose, even in a last-resort emergency apocalypse.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#30
RE: CPAP use for Coronavirus mitigation & severe pneumonia
I expect you're right Sleeprider but if there are no alternatives, which is what we're talking about here, I'm surely going to try it. I've never had pneumonia but unless there's something that precludes it, I'll be using the machine anyway just as I always do. nor will I hesitate to offer it to my wife, children or neighbors if it's a last resort.
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