|Year : 2022 | Volume
| Issue : 1 | Page : 17-21
Respiratory intensive care unit: An initiative during pandemic COVID-19
Abdullah Rashed Alharbi, Ahmed Rufai Nadama, Reem Alsergani, Haifa Alwael, Reem Alshathri, Amal Alshaibi, Norah Alshabib
Division of Pulmonology, Department of Medicine, King Saud University, Saudi Arabia
|Date of Submission||18-Feb-2022|
|Date of Decision||13-Mar-2022|
|Date of Acceptance||13-Apr-2022|
|Date of Web Publication||31-May-2022|
Abdullah Rashed Alharbi
Division of Pulmonology, Department of Medicine, King Saud University
Source of Support: None, Conflict of Interest: None
Background: With the COVID-19 pandemic having a significant negative impact on the health-care systems globally, different models of respiratory intermediate care units were shown to play a vital role in the management of COVID-19 patients, especially those with impaired oxygenation. The present study demonstrates that respiratory intermediate care units were helpful in reducing health-care cost and acting as a backup for intensive care units (ICUs) in Saudi Arabia. Design and Setting: This is a retrospective study that was carried out in King Saud University Medical City, Riyadh, Saudi Arabia, between June 15, 2020, and August 7, 2020. The study team collected information from patients' records. The data collected comprised patient's demographic information, admission site, admission criteria, and length of hospital stay. Descriptive and comparative analyses were carried out through the SPSS version 26. Results: Eighty-one patients were eligible for inclusion: 67.9% were male, 58% were above 50 years old, and similar proportions were overweight. Chronic kidney disease was the most commonly occurring comorbidity (23.5%), whereas only three patients had hypertension, and a similar number had some form of immunosuppression. In addition, 44.4% of patients were admitted through COVID wards. The mean length of hospital stay was 11 ± 5 days, with 54.3% of patients staying for more than 10 days. About 97.5% of the patients were transferred to the general medical COVID-19 ward, whereas only 2.5% were admitted to ICU. The percentage of high-flow oxygen either high-flow nasal cannula or noninvasive ventilator was 66.2 ± 15.7%. About 27.2% of the patients required oxygenation through a simple standard interface such as a mask or nasal cannula. There was no significant difference among age groups and different body mass index categories in terms of hospitalization course and oxygenation. Females used noninvasive ventilation (P = 0.008) more than males. Conclusion: Females are more prone to higher oxygenation needs compared to males with COVID-19 infections. Respiratory care units can reduce the number of females who need ICU admissions for noninvasive ventilation.
Keywords: COVID-19, noninvasive ventilation, pandemic, respiratory intermediate care units, Saudi Arabia
|How to cite this article:|
Alharbi AR, Nadama AR, Alsergani R, Alwael H, Alshathri R, Alshaibi A, Alshabib N. Respiratory intensive care unit: An initiative during pandemic COVID-19. Saudi Crit Care J 2022;6:17-21
|How to cite this URL:|
Alharbi AR, Nadama AR, Alsergani R, Alwael H, Alshathri R, Alshaibi A, Alshabib N. Respiratory intensive care unit: An initiative during pandemic COVID-19. Saudi Crit Care J [serial online] 2022 [cited 2022 Oct 2];6:17-21. Available from: https://www.sccj-sa.org/text.asp?2022/6/1/17/346352
| Introduction|| |
The World Health Organization declared the outbreak of COVID-19 as a public health emergency of international concern on January 30, 2020, and as a pandemic on March 11, 2020.
The severe acute respiratory syndrome coronavirus 2 belongs to the coronavirus group, which infects the respiratory tract leading to varying severity of respiratory disease. The virus can also cause a multiorgan infection that leads to other significant complications such as thrombosis and embolization, neurological disorders, and gastrointestinal complaints. In addition, it can vary in severity from asymptomatic patients to patients with life-threatening conditions.
The major problem with the COVID-19 pandemic is the ease and rapidness with which the virus is transmitted. This has imposed a significant burden on health-care systems due to significantly increased admissions and utilization of health-care resources on COVID-19 patients., Accordingly, countries all over the world implemented measures such as social distancing, quarantining, hand hygiene, and stay-at-home instructions to reduce the transmission rate and control the spread of the virus.,
The management of COVID-19 infections is mainly supportive in patients with mild to no symptoms of infections. This includes resting in bed, taking hot drinks, paracetamol, and a healthy diet. Nevertheless, patients with impaired oxygenation will require hospital admission to receive interventions to improve their oxygenation. It should be noted that not all patients will require invasive mechanical ventilation to improve their oxygenation. Accordingly, respiratory care units can play a significant role in reducing the health-care burden on the general intensive care units (ICUs).
Respiratory care units can help provide care for patients with impaired oxygenation who can be managed by noninvasive ventilation or nasal oxygen supply. This triage of patients can prioritize the ICU admission for patients in need of mechanical ventilation, which also will reduce the cost of health care provided during hospitalization. Hence, the present study describes the role of respiratory care units in a large Saudi hospital in reducing the health-care costs and burden on ICU s during the COVID-19 pandemic.
| Materials and Methods|| |
This is a retrospective study that included all patients with COVID-19 infections who were admitted to King Saud University Medical City, Saudi Arabia, between June 15, 2020, and August 7, 2020. All patients who had a confirmed polymerase chain reaction (PCR) for COVID-19 infection and required intensive care admission for high-flow oxygen and noninvasive ventilation were included. Patients who required mechanical ventilation or those who were hemodynamically unstable were excluded.
Data were collected from the electronic patients' medical records. The data comprised demographics of patients including age, gender, body weight, height, body mass index (BMI), comorbidities, length of hospital stay, and description of oxygenation.
Both descriptive and comparative analyses were carried out. Binary variables were described as counts and percentages, whereas numerical variables were described as means and standard deviations. Comparative analysis was carried out using Chi-square test for categorical variables and one-way analysis of variance test for numerical variables at a level of significance (P < 0.05). Statistical analysis was carried out through the SPSS version 24.
Ethics approvals were obtained from the ethics committee before the commencement of the study.
| Results|| |
Eighty-one patients participated in this study. Their characters are fully described below.
Description of the studied patients
Out of 81 patients, 67.9% were male. Their mean age was 50 ± 15.1 years, with 58% above 50 years old. The mean BMI of the patients was 26.8 ± 3.8, where 58% were classified as overweight; the most prevalent comorbidity was chronic kidney disease occurring in 23.5% of the patients, whereas only three patients had hypertension, and a similar number had immunosuppression.
As for hospital admission and length of stay, 44.4% of patients were admitted to the respiratory intensive care unit (RICU) wards, whereas the mean length of hospital stay was 11 ± 5 days, with 54.3% staying for more than 10 days. Furthermore, 97.5% of the patients were discharged from RICU to the wards, whereas only 2.5% were transferred from RICU to the ICU.
Regarding oxygenation of patients, the average high-flow nasal cannula oxygen was 66.2 ± 15.7%, whereas 27.2% of the patients needed noninvasive oxygenation. The profile of the included patients is detailed in [Table 1].
Comparison of different age groups
Hospital stay and oxygenation were compared over different age groups (below or above 50 years old), at the significance level of P < 0.05. It has been revealed that there was a nonsignificant difference among both age groups in terms of route of admission, length of hospital stay, use of high-flow oxygen, noninvasive ventilation, and transfer to ICU and the ward (P > 0.05), as described in [Table 2].
Comparison based on gender
Furthermore, both males and females were compared in terms of hospitalization and oxygenation at a level of significance (P < 0.05). It is shown that there was a significant difference between males and females in the use of noninvasive ventilation. Females used noninvasive ventilation (P = 0.008) more than males, as described in [Table 3].
Comparison of different body mass index classes
Similarly, patients were grouped into different classes of BMI and compared at a level of significance (P < 0.05). It is shown that there was no significant difference between patients of different BMI classes, as described in [Table 4].
| Discussion|| |
The human system mostly affected by COVID-19 infection is the respiratory system, where impaired oxygenation can put patients in critical conditions requiring interventions that necessitate hospital admission and sometimes ICU admission., Consequently, a patient with moderate-to-severe infection requiring oxygen supplementation may represent a significant financial burden on health-care systems which already have limited resources, particularly for COVID-19 pandemic and increasing the need for mechanical ventilators.,
The present study described the role of RICU in the management of COVID-19 patients in one of the largest hospitals in Saudi Arabia. The study demonstrated that the vast majority of patients were elderly patients, aging above 50, which highlights the higher risk of severe infection requiring hospitalization among elderly patients. Furthermore, chronic kidney disease was on top of the list of patients admitted to the hospital for severe COVID-19 symptoms with impaired oxygenation.
In terms of admissions, the study demonstrated that most patients only required ward admission. However, the length of hospital stay was relatively long, where 54.3% of the patients stayed for more than 10 days, which reflects the high cost of hospitalization associated with the admission of COVID-19 patients. Furthermore, almost a quarter of the patients (27.2%) required noninvasive ventilation.
The role of respiratory care units in reducing the health-care burden on ICUs has been demonstrated in different studies. Carrillo Hernandez-Rubio et al. evaluated the need for endotracheal intubation in ICUs when noninvasive ventilation service is available in respiratory care units. Carrillo Hernandez-Rubio et al. prospectively included seventy patients admitted to a hospital in Spain where all of them had confirmed COVID-19 PCR test and impaired oxygenation. Carrillo Hernandez-Rubio et al. demonstrated that management in respiratory care units with prone positioning and noninvasive ventilation can reduce the need for endotracheal intubation and subsequent ICU admissions.
Similarly, the present study demonstrated that noninvasive ventilation was needed in 27% of the patients, where 44.4% of patients were admitted to the wards, and 97.5% were transferred to the wards later during their treatment. Moreover, the present study demonstrated that the female gender was a significant predictor of the increased requirement for noninvasive ventilation (P = 0.008).
Furthermore, another study by Coudroy et al. examined how the use of noninvasive ventilation in respiratory care units can reduce the incidence of mechanical intubation through reviewing the literature. Through 14 studies, Coudroy et al. demonstrated that high positive end-expiratory pressure was associated with lower rates of intubation among patients. However, noninvasive ventilation was not found to reduce the need for intubation.
On the contrary, the present study did not include information about mechanical ventilation postrespiratory care unit admissions, as mechanically ventilated patients were excluded. However, it is worth mentioning that none of the included patients were readmitted to RICU, whereas only two patients were transferred to ICU. Furthermore, the findings from Coudroy et al. were nonspecific to COVID-19 patients. Future studies should explore the progress of patients admitted to respiratory ICU in terms of their need for invasive mechanical ventilation.
On the other hand, Satou et al. examined the impact of a noninvasive mode of ventilation in a retrospective study on acute respiratory distress syndrome (ARDS) patients. Satou et al. revealed a higher success rate and lower mortality in ARDS patients with the noninvasive positive pressure ventilation group. These findings support the present study which particularly focused on COVID-19 patients.
There are some important limitations that affected the outcomes of the present study. First, the included sample size was relatively small, which affected reaching statistical significance with some comparisons. Future studies should consider including a larger sample size. In addition, owing to the retrospective nature of the study, some data could have been missing or inaccurate which also may have an impact on the reliability of the study data.
| Conclusion|| |
COVID-19 represents a significant burden on ICUs due to the demanding need for oxygen supply for patients with impaired oxygenation. Respiratory care units can prevent ICU admissions for these patients through providing them with a noninvasive oxygen supply and high-flow nasal cannula oxygenation. This, in turn, will reduce costs and resources for other patients who are in ultimate need of ICU admission for mechanical ventilation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Carda S, Invernizzi M, Bavikatte G, Bensmaïl D, Bianchi F, Deltombe T, et al.
The role of physical and rehabilitation medicine in the COVID-19 pandemic: The clinician's view. Ann Phys Rehabil Med 2020;63:554-6.
Kumaraiah D, Yip N, Ivascu N, Hill L. Innovative ICU physician care models: COVID-19 pandemic at New York-Presbyterian. NEJM Catal Innov Care Deliv 2020;1.
Rasheed AM, Ftak DF, Hashim HA, Maulood MF, Kabah KK, Almusawi YA, et al
. The therapeutic effectiveness of convalescent plasma therapy on treating COVID-19 patients residing in respiratory care units in hospitals in Baghdad, Iraq. medrxiv 2020;28:357-66.
Roberts KJ, Johnson B, Morgan HM, Vrontisis JM, Young KM, Czerpak E, et al.
Evaluation of respiratory therapist extender comfort with mechanical ventilation during COVID-19 pandemic. Respir Care 2021;66:199-204.
Thibault R, Coëffier M, Joly F, Bohé J, Schneider SM, Déchelotte P. How the Covid-19 epidemic is challenging our practice in clinical nutrition-feedback from the field. Eur J Clin Nutr 2021;75:407-16.
Christopher DJ, Isaac BT, Rupali P, Thangakunam B. Health-care preparedness and health-care worker protection in COVID-19 pandemic. Lung India 2020;37:238-45.
] [Full text]
Kwok S, Adam S, Ho JH, Iqbal Z, Turkington P, Razvi S, et al.
Obesity: A critical risk factor in the COVID-19 pandemic. Clin Obes 2020;10:e12403.
Kaye L, Theye B, Smeenk I, Gondalia R, Barrett MA, Stempel DA. Changes in medication adherence among patients with asthma and COPD during the COVID-19 pandemic. J Allergy Clin Immunol Pract 2020;8:2384-5.
Candan SA, Elibol N, Abdullahi A. Consideration of prevention and management of long-term consequences of post-acute respiratory distress syndrome in patients with COVID-19. Physiother Theory Pract 2020;36:663-8.
Lew HL, Oh-Park M, Cifu DX. The war on COVID-19 pandemic: Role of rehabilitation professionals and hospitals. Am J Phys Med Rehabil 2020;99:571-2.
Winck JC, Ambrosino N. COVID-19 pandemic and non invasive respiratory management: Every Goliath needs a David. An evidence based evaluation of problems. Pulmonology 2020;26:213-20.
Severin R, Arena R, Lavie CJ, Bond S, Phillips SA. Respiratory muscle performance screening for infectious disease management following COVID-19: A highly pressurized situation. Am J Med 2020;133:1025-32.
McGrath BA, Ashby N, Birchall M, Dean P, Doherty C, Ferguson K, et al.
Multidisciplinary guidance for safe tracheostomy care during the COVID-19 pandemic: The NHS National Patient Safety Improvement Programme (NatPatSIP). Anaesthesia 2020;75:1659-70.
Iyengar K, Bahl S, Vaishya R, Vaish A. Challenges and solutions in meeting up the urgent requirement of ventilators for COVID-19 patients. Diabetes Metab Syndr 2020;14:499-501.
Rubin GD, Ryerson CJ, Haramati LB, Sverzellati N, Kanne JP, Raoof S, et al.
The role of chest imaging in patient management during the COVID-19 pandemic: A Multinational Consensus Statement from the Fleischner Society. Chest 2020;158:106-16.
Cox MJ, Loman N, Bogaert D, O'Grady J. Co-infections: Potentially lethal and unexplored in COVID-19. Lancet Microbe 2020;1:e11.
Goulart CD, Silva RN, Oliveira MR, Guizilini S, Rocco IS, Mendez VM, et al.
Lifestyle and rehabilitation during the COVID-19 pandemic: Guidance for health professionals and support for exercise and rehabilitation programs. Expert Rev Anti Infect Ther 2021;19:1385-96.
Goh KJ, Wong J, Tien JC, Ng SY, Duu Wen S, Phua GC, et al.
Preparing your Intensive Care Unit for the COVID-19 pandemic: Practical considerations and strategies. Crit Care 2020;24:215.
Carrillo Hernandez-Rubio J, Sanchez-Carpintero Abad M, Yordi Leon A, Doblare Higuera G, Garcia Rodriguez L, Garcia Torrejon C, et al.
Outcomes of an intermediate respiratory care unit in the COVID-19 pandemic. PLoS One 2020;15:e0243968.
Coudroy R, Hoppe MA, Robert R, Frat JP, Thille AW. Influence of noninvasive ventilation protocol on intubation rates in subjects with de novo
respiratory failure. Respir Care 2020;65:525-34.
Satou T, Imamura H, Mochiduki K, Ichikawa M, Takeshige K, Kamijo H, et al.
Efficacy of protocol-based non-invasive positive pressure ventilation for acute respiratory distress syndrome: A retrospective observational study. Acute Med Surg 2020;7:e465.
[Table 1], [Table 2], [Table 3], [Table 4]