Review ArticleABSTRACT
Objective: To analyze the factors that predispose the success or failure of Non- Invasive Ventilation (CPAP) by monitoring an adult patient with moderate ARDS secondary to SARS-CoV-2 for mortality reduction, through a systematic review.
Material and Methods: Quantitative research, systematic review question design structured by PIO, terms were identified, translated to scientific language through DeCS, MeSH and Elsevier topics, sources consulted: Epistemonikos, PUBMED, EBSCO, Google Academic, BMJ, Springer, as a research strategy the Boolean operators AND and NOT were used, articles with systematic review design were considered as criteria, primary studies from the observational type, cohorts, cases and controls not older than 5 years, excluding studies in pediatric patients.
Results: 1571 articles were located, 1515 were eliminated for not having a direct relationship with the use of CPAP in SARS-CoV-2, 56 articles were selected for critical reading (files 3.0). 44 were eliminated for not meeting the eligibility criteria and 12 were selected. They were ranked by the SING scale assigning a level of evidence and grade of recommendation.
Conclusions: Non-invasive ventilation with CPAP has been used to treat patients with respiratory insufficiency due to secondary ARDS to SARS-CoV-2. This review proves that mortality is directly related to different influential variables, among which the following stand out: comorbidities, age, PaO2/FiO2 and the no intubation order.
Keywords: Continuous Pressure to the Air Ways; SARS-CoV-2; Mortality; Adult Respiratory Distress Syndrome
Abbreviations: CPAP: Continuous Positive Airway Pressure; NIV: Non-Invasive Ventilation; NMV: Non- Invasive Mechanical Ventilation; ARDS: Acute Respiratory Distress Syndrome; PaO2: Arterial Oxygen Pressure; FiO2: Fraction of Inspired Oxygen; PEEP: Positive End-Expiratory Pressure; ACE2: Angiotensin- Converting Enzyme 2; IOP: Question, Intervention, Outcome; DeCs: Descriptors in Health Sciences; MeSH: Medical Subject Headings; WHO: World Health Organization; ICU: Intensive Care Unit; SING: Scottish Intercollegiate Guidelines Network
Introduction
SARS-CoV-2 infection, is a health problem that caused a global pandemic, has its beginnings in Wuhan, a province belonging to Hubei, China, where it developed an outbreak of pneumonia of unknown cause, which generates tension to international level. Coronavirus was declared as an international public health emergency, there have been registered around 458 million confirmed positive cases of COVID-19 and a total of 6.04 million of world-wide deaths [1,2]. SARS-CoV-2 uses the spike (S) protein, densely glycosylated to enter the host´s cellules, binding with great affinity to the receptor of the enzyme convertor of angiotensin (ACE2), said enzyme is found in type II alveolar cells. The Coronavirus-2019 (COVID-19) cases present asymptomatic patterns, low, moderated, and serious ones, including: pneumonia, Acute Respiratory Distress Syndrome (ARDS) sepsis, and septic shock, which would have the main impact on respiratory insufficiency, therefore, it would demand major interventions and more complexity to a point where the affected patients would require hospitalization in the “Unidad de Cuidados Intensivos” (UCI for its initials in Spanish) to receive appropriate treatment and avoid severe complications that would put in risk the patient’s life [3].
The SDRA it’s a form of pulmonary edema with no cardiogenic cause that comes from an alveolar injury, which is caused by an inflammatory process of local origin or systematic one [4]. The classic diagnosis is made based on The Berlín criteria that works to evaluate the temporality, the obtained radiography, the edema’s origin, and the oxygenation, classifying it low with a Blood Oxygen Pressure (PaO2) / Fraction of inspired oxygen (FiO2) of 300- 200 mmHg, moderated with PaO2/FiO2 de 100-199 mmHg and severed with PaO2/FiO2 <100mmhg, all of them with Positive-end expiratory pressure (PEEP) >5cmH2O [5]. Cornaviru’s patients and patients with severe respiratory insufficiency are hospitalized in the UCI with hypoxemia that most of the time requires a way of respiratory support. One of the most common therapies is the “Ventilación No Invasiva” (VNI for its initials in Spanish) which consists of the administration of the ventilatory support without an artificial airway, such as an endotracheal tube or a tracheostomy, instead, they do it through a facial mask, nasal or a hull system [6]. The considered criteria for introducing non-invasive respiratory support in the acute respiratory failure are the Clinical criteria: Moderate-severe Dyspnea accompanied by signs of labored breathing, use of accessory musculature or paradoxical abdominal movement, Tachypnea higher than 30 rpm, and Gasometric criteria: PaO2/FiO2 <200 mmHg and Acute ventilatory failure with pH< 7,35 with PaCO2 > 45 mm Hg) [7].
The VNI for Continuous Positive Pressure in the Airway (CPAP for its initials in Spanish) as applicable therapy in adult patients with COVID 19 reduces the necessity of intubation concerning conventional oxygen therapy [8]. We have to take into account that not all patients benefit from the Invasive Mechanical Ventilation (VMI), for this reason, it is important to establish the opportune time for the implementation of CPAP, evaluating the deterioration or increase of the PaO2/FiO2, as the principal determinant of the hypoxia correction. This investigation is relevant for the timely attention that we can give to patients that go through an infection of SARS CoV-2 in hospitalization. The objective is to analyze the factors that predispose the success or failure of the non-invasive ventilation (CPAP) through the monitoring of the adult patient with SDRA secondary to SARS-CoV-2 for the decrease of mortality, by a bibliographic review.
Material and Methods
Quantitative research was conducted, a kind of systematic revision through the phases of Nursing Based in Evidence using the PRISMA declaration, the question of the investigation was formulated based on the PIO model, the characteristics of the population needed for this investigation were senior patients whose clinical condition was: SDRA secondary to SARS-CoV-2. Carried out in a phase from September 1, 2021, to March 2022.
Researching Strategy
A question was formulated in the PIO (Patient, Intervention, Outcome) format. The analysis process and preparation for research was realized in a list of natural language terms, for its localization and traduction to a documental language a Descriptor en Ciencias de la Salud (DeCS) was used [9], el Medical Subject Headings (MeSH) [10] and Topics de la editorial Elsevier (Table 1) [11]. As a strategy for precise searching terms with the proper language were used to form research chains (CPAP AND covid-19 AND Mortality, COVID-19 AND Non- invasive Ventilation AND CPAP NOT CNAF AND Mortality, CPAP AND COVID 19) using the booleans AND and NOT. Free terms were used for the sensitive search. The used sources of information were databases (Epistemonikos, PUBMED and EBSCO), Search engines (Google academic), Electronic journals (BMJ, Editorial: Springer). The Sci-Hub tool was used for the recovery of the full-text articles, while the title and abstract were read for the initial selection of the articles. Articles both in English and in Spanish were published about the adult patients with ARDS secondary to SARS-CoV-2 and the mortality factors; the articles that were used are systematic designs and primary observational case studies.
Descriptive observational studies, case reports and letters to the editor, evidence published with more than 5 years, studies in populations under 18 years of age and in animals, as well as those for which the full text could not be accessed, were excluded. For the synthesis and interpretation of the evidence and to answer the research question formulated, the 12 scientific articles included in this review were ranked using the SIGN (Scottish Intercollegiate Guidelines Network) with the purpose to assign the level of evidence based on the design and the degrees of recommendation to assess the reliability of the intervention to be recommended (Table 1). To evaluate the risk of bias and the quality of the studies included in this analysis we evaluated based on the characteristics of each design (Table 2). In this article, the main bias analyzed it’s been selected mainly due to the predominance of observative studies of cohort. These biases were addressed by doing a triangulation of critical reading, getting to an agreement of shared opinions in case of discordance. This strategy consisted in reviewing at least by three autors each study that was included. So in this way we can get more reliable information.
Table 1: Translation of free terms into documentary language.
Note: ARDS: Acute Respiratory Distress Syndrome, CPAP: Continuous Positive Airway Pressure.
Table 2: Risk of bias on the articles.
Results
According to the research done by Epistemonikos, EBSCO, Google scholar, BMJ and SPRINGER, 1571 articles have been found, from which 56 were selected by title and summary for the recuperation of the full text, while having in mind the inclusion and exclusion criteria mentioned before and having them evaluated with the FLC 3.0 platform (Figure 1 & Table 3) [12-23].
Table 3: Evidence synthesis.
Note: NIV: Non-Invasive Ventilation, NIRS: Non-Invasive Respiratory Support, IMV: Invasive Mechanical Ventilation, ICU: Intensive Care Unit, CPAP: Continuous Positive Airway Pressure, PaO2: Arterial Oxygen Pressure, FiO2: Inspiratory Fraction of Oxygen, SARSCoV- 2: Severe Acute Respiratory Syndrome associated with Coronavirus 2, IOT: Endotracheal Intubation, ARDS: Acute Respiratory Distress Syndrome, NIPPV: Non- Invasive Positive Pressure Ventilation, AHRF: Acute hypercapnic respiratory failure.
Figure 1: Evidence selection
Discussion
The main findings of this review can be summarized as follows: In all articles, mortality was higher in patients >60 years of age, who suffered from comorbidities such as hypertension, diabetes, lung, kidney and heart disease, Likewise, criteria such as male gender and a decreased PaO2/FiO2 ratio play an important role in the outcome of patients with COVID-19, since they were associated with greater failure of NIV-CPAP. 58% of the articles included the order of no intubation, based on criteria such as present comorbidities, chronic diseases, Cammarota, et al. [12] adds among these criteria the decision of the patient, the family and the multidisciplinary team, on the other hand, Faraone, et al. [17] includes all the aforementioned criteria, adding short life expectancy, since the patients who had a higher incidence of acquiring ARDS secondary to SARS- CoV-2 were patients aged >60 years. On the other hand, Invasive Mechanical Ventilation (IMV) was indicated in patients with NIV-CPAP failure who presented fatigue, respiratory rate >30, decreased level of consciousness, but Barone, et al. [18] Includes hemodynamic instability, defining it as a decrease in systolic blood pressure <90mmHg despite the use of vasoactive drugs, while Walker et al considered higher oxygen requirements, decreased PaO2/FiO2 and increased shallow breathing, in addition to other criteria already mentioned.
Regarding efficacy, all the articles agree that non-invasive CPAP ventilation is related to a greater probability of survival, however Ashish, et al. [13] It refers that when its onset is less than four days after admission and in selected patients it can have significant benefits both for the patient’s well-being and for the resources of the health system and in the same way a potential benefit for patients treated with order not to intubate, as opposed to being treated with oxygen alone, on the other hand Kofod, et al. [22] reports that the prolongation of the use of CPAP for more than one week compromises successful weaning in these patients with ARDS, thus showing that the duration of CPAP time was an important predictor of mortality in patients. About the nursing care function, the evidence indicates that NIV-CPAP monitoring in these patients must be constant in order to identify changes in physiological parameters that may predispose the failure or success of NIV-CPAP therap. Patients affected by ARDS due to COVID-19. The main fears in relation to the studies were expressed by the risk of lung injury related to NIV-CPAP, in which close monitoring and individualized titration of ventilatory pressures were suggested. Another concern is the high risk of aerosol generation that can cause contagion in health personnel, so the use of bacterial filters is recommended to apply NIV-CPAP, avoiding the spread of the virus. Use of Personal Protective Equipment (PPE) when coming into contact with patient care.
Conclusion
The application of NIV-CPAP in patients with ARDS secondary to SARS-CoV-2 proves to be feasible in selected patients under 60 years of age, with few or no comorbidities, with a mild to moderate ARDS level according to the Berlin classification, reducing the mortality rate when they are treated in the first four days after hospital admission, performing continuous monitoring by qualified personnel. The limitations of our study are related, for the most part, to the observational and retrospective design of the included investigations, however, in the future, studies with a higher level of evidence are required to carry out more reliable evaluations.
Conflict of Interest
The authors declare that they have no conflict of interest in relation to this work.
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