Continuous positive airway pressure for respiratory support during COVID-19 pandemic: a frugal approach from bench to bedside

Carteaux, Guillaume; Pons, Manuella; Morin, François; Tuffet, Samuel; Lesimple, Arnaud; Badat, Bilal; Haudebourg, Anne-Fleur; Perier, François; Deplante, Yvon; Guillaud, Constance; Schlemmer, Frédéric; Fois, Elena; Mongardon, Nicolas; Khellaf, Mehdi; Jaffal, Karim; Deguillard, Camille; Grimbert, Philippe; Huguet, Raphaëlle; Razazi, Keyvan; de Prost, Nicolas; Templier, François; Beloncle, François; Mercat, Alain; Brochard, Laurent; Audard, Vincent; Lim, Pascal; Richard, Jean-Christophe; Savary, Dominique; Mekontso Dessap, Armand

BACKGROUND: We describe a frugal approach (focusing on needs, performance, and costs) to manage a massive influx of COVID-19 patients with acute hypoxemic respiratory failure (AHRF) using the Boussignac valve protected by a filter (“Filter Frugal CPAP”, FF-CPAP) in and out the ICU. METHODS: (1) A bench study measured the impact of two filters with different mechanical properties on CPAP performances, and pressures were also measured in patients. (2) Non-ICU healthcare staff working in COVID-19 intermediate care units were trained with a video tutorial posted on a massive open online course. (3) A clinical study assessed the feasibility and safety of using FF-CPAP to maintain oxygenation and manage patients out of the ICU during a massive outbreak. RESULTS: Bench assessments showed that adding a filter did not affect the effective pressure delivered to the patient. The resistive load induced by the filter variably increased the simulated patient’s work of breathing (6–34%) needed to sustain the tidal volume, depending on the filter’s resistance, respiratory mechanics and basal inspiratory effort. In patients, FF-CPAP achieved pressures similar to those obtained on the bench. The massive training tool provided precious information on the use of Boussignac FF-CPAP on COVID-19 patients. Then 85 COVID-19 patients with ICU admission criteria over a 1-month period were studied upon FF-CPAP initiation for AHRF. FF-CPAP significantly decreased respiratory rate and increased SpO(2). Thirty-six (43%) patients presented with respiratory indications for intubation prior to FF-CPAP initiation, and 13 (36%) of them improved without intubation. Overall, 31 patients (36%) improved with FF-CPAP alone and 17 patients (20%) did not require ICU admission. Patients with a respiratory rate > 32 breaths/min upon FF-CPAP initiation had a higher cumulative probability of intubation (p < 0.001 by log-rank test). CONCLUSION: Adding a filter to the Boussignac valve does not affect the delivered pressure but may variably increase the resistive load depending on the filter used. Clinical assessment suggests that FF-CPAP is a frugal solution to provide a ventilatory support and improve oxygenation to numerous patients suffering from AHRF in the context of a massive outbreak. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13613-021-00828-2.