The eye may be the spy of injury related to NIV interface and prone positioning
Paola Pierucci, Maria Luisa De Candia, Andrea Marzullo, Federica Mele, Francesco Introna, C. Agrisani, Giulia Ingoglia, Cesare Gregoretti, Giovanna Elisiana Carpagnano · Pulmonology · 2022
T a g g e d P Noninvasive ventilation (NIV) and prone-positioning (PP) are life saving measures in patients with moderate COVID-19 related ARDS.[1][2][3][4][5] Risks related to the use NIV interfaces and PP are already individually described in literature.[6][7][8] To the best of our knowledge, in this case of a 86 year-old woman we are the first to describe the complication related to the combined use of PP and NIV via an oro-nasal mask interface.Informed written consent to publication of her clinical data was obtained from the patient's next of kin.The patient had refused COVID-19 vaccination and in November 2021 she tested positive for SARS-CoV2 infection via rapid antigen test.She was admitted after three days to the Emergency department (ED) of Bari University Hospital with persistent fever, dizzy cough and dyspnoea despite having received oral prednisone (50 mg/die), and azithromycin 500 mg/daily at home.She was rapidly escalated from conventional oxygen therapy to High Flow Nasal Oxygen (HFNC) set at 60 litres/minute, 31°C, with an oxygen fraction (FiO 2 ) of 70% for desaturation on venturi mask.Arterial blood gas test on HFNC showed a PaO 2 and FiO 2 ratio (P/F) of 114.Chest Xray showed bilateral infiltrates.According to the Berlin definition, moderate ARDS was diagnosed.Due to her old age and comorbidities, no indication for intubation was granted by ICU physician, and she was admitted to the Respiratory Intermediate Intensive Care COVID-19 Unit (RICU).CT scan confirmed bilateral lungs ground-glass opacities and middle and lower lobes subpleural consolidations (Fig. 1A).During 2 nd day in RICU, the patient was switched to NIV due to increasing dyspnea, respiratory rate and use of accessory muscles.Pressure Support Ventilation (PSV mode) was started at 8 cmH2O above 11 cmH 2 O of positive end expiratory pressure (PEEP) using a ventilator in intentional leak configuration (V60, Philips; Respironics,USA).An 8-hour rotational interface strategy was started using either a "non-vented" oro-nasal masks (PerformaTrak Philips; Respironics,USA or Flexifit 431-Fisher&Paykel) while in lateralpositioning and "non-vented" full-face mask (PerforMax NOCTN111Respironics USA) while supine.The rationale behind the use of "non vented" interfaces was to allow the a A.