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Rationale: How to provide advanced respiratory support for coronavirus disease (COVID-19) to maximize population-level survival while optimizing mechanical ventilator access is unknown. Objectives: To evaluate the use of high-flow nasal cannula for COVID-19 on population-level mortality and ventilator availability. Methods: We constructed dynamical (deterministic) simulation models of high-flow nasal cannula and mechanical ventilation use for COVID-19 in the United States. Model parameters were estimated through consensus based on published literature, local data, and experience. We had the following two outcomes: 1) cumulative number of deaths and 2) days without any available ventilators. We assessed the impact of various policies for the use of high-flow nasal cannula (with or without “early intubation”) versus a scenario in which high-flow nasal cannula was unavailable. Results: The policy associated with the fewest deaths and the least time without available ventilators combined the use of high-flow nasal cannula for patients not urgently needing ventilators with the use of early mechanical ventilation for these patients when at least 10% of ventilator supply was not in use. At the national level, this strategy resulted in 10,000–40,000 fewer deaths than if high-flow nasal cannula were not available. In addition, with moderate national ventilator capacity (30,000–45,000 ventilators), this strategy led to up to 25 (11.8%) fewer days without available ventilators. For a 250-bed hospital with 100 mechanical ventilators, the availability of 13, 20, or 33 high-flow nasal cannulas prevented 81, 102, and 130 deaths, respectively. Conclusions: The use of high-flow nasal cannula coupled with early mechanical ventilation when supply is sufficient results in fewer deaths and greater ventilator availability.

Rationale: Both acute respiratory distress syndrome (ARDS) and intensive care unit (ICU) delirium are associated with significant morbidity and mortality. However, the risk of delirium and its impact on mortality in ARDS patients is unknown.Objectives: To determine if ARDS is associated with a higher risk for delirium compared with respiratory failure without ARDS, and to determine the association between ARDS and in-hospital mortality after adjusting for delirium.Methods: Prospective observational cohort study of adult ICU patients admitted to two urban academic hospitals.Measurements and Main Results: Delirium was assessed daily using the Confusion Assessment Method for the ICU and Richmond Agitation and Sedation Scale. Of the 564 patients in our cohort, 48 had ARDS (9%). Intubated patients with ARDS had the highest prevalence of delirium compared with intubated patients without ARDS and nonintubated patients (73% vs. 52% vs. 21%, respectively; P

Active smokers are prevalent in hospitalized and critically ill patients. Cigarette smoking and nicotine withdrawal may increase delirium in these populations. This systematic review aims to determine whether active cigarette smoking increases the risk for delirium in hospitalized and intensive care unit (ICU) patients.A systematic search of English-, Spanish-, and French-language articles published from 1966 to April 2013 was performed. Studies were included if they measured cigarette smoking as a risk factor and delirium as an outcome in adult hospitalized or ICU patients. Methodologic quality of studies was assessed using both the validated Newcastle Ottawa Scale and an additional evidence-based quality rating scale.A total of 14 cohort studies of surgical and ICU populations were included in the review. No studies in non-ICU inpatients were identified. The incidence of delirium ranged from 9 to 52%, and the prevalence of active smokers ranged from 9 to 44%. The quality of assessment for active smoking varied widely. None of the studies used biochemical measures to determine cigarette smoke exposure. Of the six studies restricting the smoking group to active smokers only, active smoking was independently associated with delirium in one study, trended toward an association in one study, and showed a dose response in one study. Quantitative summary measures were not calculated due to study heterogeneity and missing data.There is currently insufficient evidence to determine if cigarette smoking is a risk factor for delirium. Future studies should consider using biochemical measures of cigarette smoke exposure to objectively quantify smoking behavior.

Delirium is a form of acute brain injury that occurs in up to 80% of critically ill patients. It is a source of enormous societal and financial burdens due to increased mortality, prolonged intensive care unit (ICU) and hospital stays, and long-term neuropsychological and functional deficits in ICU survivors. These poor outcomes are not only independently associated with the development of delirium but are also associated with increasing delirium duration. Therefore, interventions should strive both to prevent the occurrence of ICU delirium and to limit its persistence. Both patient-centered and ICU-acquired risk factors need to be addressed early in the ICU course to maximize the efficacy of prevention strategies and to improve long-term outcomes of ICU patients. In this article, we review strategies for early detection of patients who are delirious and who are at high risk for developing delirium, and we present a clinically useful ICU delirium prevention and reduction strategy for clinicians to incorporate into their daily practice.

From the Authors: We thank Dr. Manthous for his comments regarding our article (1). Dr. Manthous offered some interesting hypotheses on reasons for the continued use of heavy sedation in mechanically ventilated patients, despite strong evidence demonstrating improved outcomes with a lighter and more targeted approach. We wholeheartedly agree with his view that there is an urgent need for greater adoption of guideline-concordant sedation practices. In addition to a need to address knowledge gaps and clinical inertia at an individual physician level, changing sedation practices requires education and a transformation in the attitudes and behaviors of the entire multidisciplinary ICU team to a “less is more” sedation culture. One of the first steps in improving ICU-level sedation practices involves a close examination of barriers specific to each ICU setting and a systematic, multidisciplinary team–based approach to plan, educate, and implement these new practices. Effective approaches to tackling these barriers and implementing best evidence-based practices have been widely published in the quality improvement literature. The Plan-Do-Study-Act (PDSA) framework is an example of an iterative approach that we have used to effectively implement delirium monitoring and sedation protocols (2). For example, a team could plan to implement a sedation protocol (Plan), implement the protocol (Do), determine if the protocol actually reduced sedative use (Study), and determine how refine the sedation protocol based on the findings (Act). In addition, a number of excellent resources for clinicians interested in implementing these changes are easily accessible online. These include (1) http://www.icudelirium.org/ by the Vanderbilt ICU Delirium and Cognitive Impairment and Study Group, (2) http://www.iculiberation.org/Pages/default.aspx by the Society of Critical Care Medicine, and (3) http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx from the Institute for Healthcare Improvement. Finally, with the clear and convincing evidence that clinical outcomes can be further improved by coordinating sedation lightening with ventilator weaning trials and early mobilization, waking up our critically ill patients should be considered the first step in rehabilitating our ICU patients (3, 4). Quality initiatives on ICU sedation should serve as a gateway toward implementing these multicomponent nonpharmacologic delirium prevention and reduction strategies. While we should learn from our past missteps, history has also shown us that we are capable of changing our practices to better care for our patients (5). As one of the five key concepts featured in the interdisciplinary Critical Care Societies Collaborative “Choosing Wisely” list, a critical reappraisal of our sedation practices is now under the national spotlight (6). Let us heed this call to action and ensure that these conversations and changes are occurring in our ICUs.