Covid-19 Treatment ProtocolBeing adequately equipped, trained and correctly informed to treat covid19 patients is no small matter.
Currently it is evident that According to the World Health Organization (WHO), some 80% of people with Covid-19 - the disease caused by coronavirus - recover without needing hospital treatment. But, one person in six becomes seriously ill. In these severe cases, the virus causes damage to the lungs, causing the body's oxygen levels to drop and making it harder to breathe.
Of patients hospitalized with COVID-19, 25% require ICU admission.
- In terms of our capacity to manage this, mHBOT options could be used to lessen the burden of patients requiring ICU.
Profound hypoxemic respiratory failure from ARDS is the dominant finding in critically ill patients. Common complications include acute kidney injury (AKI), the late development of cardiac injury, sepsis, shock, and multi-organ failure
- mHBOT has been cited to have anti-inflammatory effects and decreases cellular damage.
For most critically ill patients with COVID-19, we prefer the lowest possible fraction of inspired oxygen (FiO2) necessary to meet oxygenation goals, ideally targeting a peripheral oxygen saturation between 90 and 96 %
- It is feasible that mHBOT can be regulated to provide that at 1,3 ATA, with the added benefit that the raised pressure does the work.
- mHBOT oxygen concentrators provide this at a flow rate of 10 litres/min, that can be adjusted as required.
The use of HFNC and NIV is controversial based on infection control concerns and the frequent need for mechanical ventilation despite these measures.
- It would be of great value to include mHBOT as a modality. Using a varied approach studying and implementing a strategy to determine which type of oxygenation mask or HFNC would give best results with recommendations recorded for research purposes.
In patients with COVID-19 who have acute hypoxemic respiratory failure and higher oxygen needs than low flow oxygen can provide, we suggest selective use of non-invasive measures like mHBOT rather than routinely proceeding directly to intubation .
- mHBOT could provide this support with non re-breather oxygen masks with reservoirs to ensure maximum oxygenation at 1,3 ATA that is proven to be efficient yet non injuring. As an example we might trial HFNC in younger patients without comorbidities who can tolerate HF nasal cannulae. In contrast, one may need to proceed directly to early intubation in patients at higher risk or with comorbidities.
Among the non-invasive modalities we suggest HFNC rather than NIV (Grade 2C). Our preference for HFNC is based upon limited and inconsistent data, which, on balance, favours HFNC compared with NIV in patients with non-COVID-19-related acute hypoxemic respiratory failure. NIV via a full-face mask (with a good seal) may be appropriate in patients with indications that have proven efficacy including acute hypercapnic respiratory failure from an acute exacerbation of chronic obstructive pulmonary disease, acute cardiogenic pulmonary edema, and sleep disordered breathing. Patients with potential haemothorax should not receive mHBOT.
For critically ill patients with COVID-19, intubation should not be delayed until the patient acutely decompensates since this is potentially harmful to both the patient and healthcare workers. We have a low threshold to intubate those who have:
- Rapid progression over a few hours
- Failure to improve despite HFNC >40 L/min and FiO2 >0.6
- Development of hypercapnia
- Hemodynamic instability or multiorgan failure
Intubation is a high risk procedure for aerosol dispersion in patients with COVID-19 and attention should be paid to donning full personal protective equipment (PPE) with airborne precautions as well using equipment that minimizes dispersion and the development of protocols for the procedure.
For patients with COVID-19 who fail LTVV, prone ventilation is the preferred next step
Our recommendations for new Covid-19 Hospitals being planned.
- Several isolation wards should be separated for housing 2 – 4 mHBOT Chambers, all spaced 4m apart with protective sheeting between each chamber.
- Consistent disinfection protocols should be observed in line with recommended and established guidelines to prevent cross contamination of patients and care workers.
- All personnel attending should wear appropriate PPE with airborne precautions.
- Treatment at 1,3 ATA with 70% - 90% saturation of oxygen through a non-rebreather mask or HFNC as required should be given rotationally.
- Sessions of 120min can be given either once or twice daily initially. After week 1, daily sessions of 120min can continue until patients experience relief.
- It is recommended to follow preventative measures to control infection between sessions using the established disinfection protocol for all medical equipment.
- This will enable each OxyVive mHBOT chamber to treat 5 patients with disinfection breaks of 50min on a rotational cycle starting at 05:00 daily.
- It is highly recommended that patients are strictly monitored pre- and post- mHBOT sessions via pulmonary ultrasound and or tomography. Results of the progress of patients would be critical in determining the further success of this already validated regimen.
- An improvement in general oxygen saturation is expected within the first days.
- Pulmonary hypoxia should diminish and patients should not require mechanical ventilation within 1 – 2 weeks depending on the severity of the initial pneumonic state of the patient concerned.
- There is a growing body of evidence that shows that early treatment of severely ill patients with mHBOT could provide a greater efficiency of other treatment protocols including NIV between mHBOT treatments.
Studies show that leukocytes perform best at oxygen levels above 300 mmHg, levels only achievable with supplemental oxygen through HBOT.