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Good evening, everybody. My name is wrong card. Think I'm associate professor for Portal Medical School and also the the chair off the N I T group from the European Respiratory Society. And it's bean really a non for me to be here today to present you some guidance on the respiratory support part off ways in patients with cov 19. This is my agenda. So I'm going to briefly and the introduced the topic and then discuss a little bit about what is really the risk off every so generation from the non invasive respiratory therapies. So briefly review with you about the trends off this therapist during this cov 19 pandemic and then go directly into our algorithm to define how to start, when to do it and when to stop and to win. Elise therapies related to acute respiratory failure of Kobe 19. Now it's been a little bit about new, uh, therapy devices and conclude So I think the discussion started very early about the idea off intubating her early the East patients and how colleagues from the arena where some of them were really pushing forward to this concept. But I think that now we have more and more evidence saying that it's okay to delay this incubation. This is a very recent study from France and multi center study perspective study really showing you that, um, if the patients are really intubated, there is bean on increase risk off mortality. It's 6 60 days. This is another very recent study from also a multi center study showing out. So that's starting with high flow nasal oxygen in patients with acute respiratory fell associated cov 19. It's not the litter IUs, and even it reduces the three ventilatory three days compared to an, um, higher intervention like a Hurley intubation. So I think that and also that translates into reduced in a in a hospital. Mortality. Um, this was three idea from the societies across the globe. So that includes also the any chest that was really favoring CPAP as initial intervention. There was some other authorities that we're recommending instead I Flonase cannula. So it was a little after a genius kind of recommendations. I think that now maybe we can change a little bit and we're seeing, uh, countries like Italy that was proposing Alma cpap of the first line intervention that moving a little bit towards I Flonase Cannula. I like very much. This lies a little bit busy that it's just show you What is the transitions that's patients go across when they are admitted to the hospital? So, um, this is a us, uh, that base. So you can see at the zero. There are patients that are mechanical. Eventually it'd some of them go to Lifelock. Oh, some of them go to conventional oxygen. And this is the transitions that are quiet difference. So some patients with conventional oxygen that go to I flow on die because they have, Ah, a ceiling treatment here, Uh, some of them from oxygen go directly to the I see you on and some of them go to mechanical ventilation and then from mechanical ventilation, they can either, you know, be discharged. Okay, go again into a pathway off non invasive respiratory therapies like active flow, mechanical ventilation. And this is a little bit What is going to be my talk today mentioned you on these kind of trajectories that we can see on a regular basis in our patients when they are admitted to hospital to definitely start oxygen therapy. And I think we should be dosing, especially the masks that have some filters or using a nasal cannula. It's with a surgical masks on top, because we can still have some dispersion off particles. And I think that, um, these part here where you use a reservoir mask. I think there is a really on some arguments off. Why don't we use I, Flonase or Cannula earlier on? But anyway, that's going to be my topic. And then after I Flonase, so can a lot of oxygen. We can go either to CPAP from mask and and then elements, or we can choose either ones, and then even we can upgrade to buy level, and that's what we're going to discuss. Don't forget this this part here of the picture, which is prone ing, which I think more, more people are using even when the patient is on conventional oxygen. And we can do this if the patient tolerates and there is a good effectiveness. So the discussion about is a noninvasive respiratory therapy is really, uh, aerosol generating procedures. So everybody knows that the works from the group from Hong Kong Professor David who is, and that we would summarize here comparing different, um, set up So by level C pop a full face mask and also the the helmet. And as you can see, the more pressured the higher maximum exile air distance you got. And, um, the only, uh, negligible this person is when using the's mask water air with the anti anti s fixes valve closed. And when you're using the the helmet where you have negligible maximum hair distance Excellent shin This work from the UK from percent Professor Simon's from the Brompton, I think is really game changer because for the first time, what her group it was just to compare the dispersion. The droplet counts with an IV versus a modified an IV which is shown here in this picture here, where you can see there is a viral foot filter before the eggs elation, pork and as you can see by the particles by the droplets between 5 to 10 microns and above 10 microns that you can see that there is no increased with these modified and I'd be Whereas when you have the normal an IV with the expert or e port open, there is a small increased especially in that more than 10 microns, uh, droplets. And, of course, when you're using a nebulizer here where you can see a higher, um, droplet count specially off particles, lower dimension particles, the evidence that we have about, um, I Flonase or cannula is also pretty good. This is also from a Professor Furies lab showing that, um, with nasal cannula and with different levels off low, you can see there are some leakage that is especially adult lateral part, especially if there is some, uh, some, uh, the's location of the cannula. So it's important when you're using a nasal cannula for I flow oxygen and there are a couple of different, um, nasal prongs in the market you have to teach. Choose the right time. Mention off off the nasal Bronx to be sure that this part here is less prone to have some leakage. There are then some pretty nice bench studies about the usefulness off putting a mask on top off nasal cannula for I flow oxygen therapy. You can see the dice Persian of the aerosols and droplets during nasal cannula without a mask at surgical mask, and you can see here very clearly there is these decrease a very recent paper now showing again the importance of using a surgical mask on top off a common nasal cannula for low flow oxygen and also an important for Flonase. Oh, cannula, this is a patients or healthy volunteers coughing, and you can see very clearly the the droplets going through. And then you can see the difference when you put a mask on top off these devices. And this is a video showing what I was saying earlier early showing that there is some important improvement in the droplets count when you put a surgical mask on talk. It is a very recent publication from AH UK Group. Very elegant study comparing the every soul counts that droplet counts with either CPAP and I flown is okay. No, this is the baseline measurement. And as you can see with when the coughing is the really, uh, risky, um, situation where you have very i droplet council. As you can see, when the patient is with a CPAP with a filtered mask, you can see that the droplets comes are pretty low. And compared to the baseline measurements, the Eiffel does not generate additional aerosols. The's office conclude and this is also I Flonase. Okay, Angela, with a surgical mask on top, there is some aerosol generated by the machine and not by the patient. And it's unlikely that it's posing extra clinical risk, given the very low size. So some authors, in conclusion on I'm absolutely in agreement with them that our noninvasive respiratory therapies are really not aerosol generating procedures, but rather that thesis bursting by or aerosols father away from from the patient. And that's what we have to be aware off to last slides on this topic. A really world situation on this is a study from Hong Kong showing a case of a patient that was treated in a nice elation room with negative pressure. He was on my flow during the day on a nocturnal, and I'd be during the night. And, as you can see in red, uh, the, uh, the places where there was a positive viral cultures from SARS cove it, too, and you can see there are some bits off off the virus. Close that 1 m to the bad for the rays of the bed. That was really expected, but there was no isolation off off viral particles from the hair in Let's, which is rather reassuring. And this is another study also published recently, Um, and also showing that we, the this's nine patients on high flow nasal cannula, pretty severe situation in also a negative pressure room. And, as you can see here that the particles were was really lower when the patient, um, was wearing a mask and there were no a lot of particles a 20 ft from the head of the patient. So let's go now to the trends off the's therapist during coffee and 19. As you can see, we at a pretty good number off off studies. So the majority are observational retrospective. Uh, this is the time off my revision. So, around one 1005 100 patients, um, there was only one paper, actually from the UK that used negative pressure room. So the majority off the studies was with a good respiratory failure off over 19 was performed in known negative pressure rooms. And as you can see, the mean success off CPAP was 61 the minutes obsessed off noninvasive ventilation 53 and a little bit higher for I Flonase cannula. Let's go a little bit deeper about these results. And one thing that is really important is to analyze what is the infection rate of the elf care workers that were participating in these studies and a Z concede. There was one study that had a high number off, um, cases around the after work is this was done during the first wave in Italy. Pretty overwhelmed emergency rooms. You remember the pictures and the videos that we had that of those times. These patients were really close together and it were we having, like, 22.5% off after work is infected. After that, you can see that the there was even some Siris like V A L0 cereal from Italy on a respiratory intensive care unit at zero infection rate and also from Allibert e also zero infection, right? Unfortunately, no. All the papers reported the infection rate. But as you can see, that the mean infection rate was 6.4, which was pretty okay and sometimes lower compared to some serious publishing the literature off other elf care workers in other places in the hospital, um, looking at the success rate compared with the severity off respiratory failure we can see that there is not a good relationship between this. So they are Siris with pretty severe patients. Like seriously, from, um, Guy Age and Francois. They had a very high success rate above 70% on patients with average 124 of the A 02 f i 02 and a Z concede. Hear a very similar population with the same level off. Uh, P 02 f i 02 ratios In the I see you, you can see that they have lower lower success rate. So I think it's very hard to compare these studies. But I just wanted to put the studies all together for you too in perspective. And what is important is how early are you intervening? Oh, her early. Are you using high flow nasal cannula? As you can see here in these studies that had the lower we don't know really how early it waas because the office didn't show us the door to mask time. And I think this is important albumin. We should report, for instance, here in these I see you study from Golden in, um in South Africa. It was really late this's intervention here whereas, for instance, in the study from guy in in France it was pretty early. So I think our early are you performing and I will come back to you after after some slides. And this is the same situation for CPAP at it is you can see here the the study from Italy Rosasco cloudy Bruce Osco as a pretty high success rate, even with patient with low T a 02 f. I choose around 120 on compared with this study from Duka, which was the study performed on Lombardia at the beginning, Off off the pandemic. So it's of course, there are some situations that we need to understand, and this is also the success rate related to be able to if I to of an IV again the same the same correlation a case in yet just to move forward. This is a very famous trial, the recovery trial, using dexamethasone for a transfer to a failure of Kobe 19. As you can see here, especially for the patients that were receiving oxygen, there was really a n'importe no effect off next semester. So however, this dexamethasone group with a group receiving, Um uh, noninvasive respiratory therapies. But we don't know really the percentage of patients that were receiving noninvasive insulation with the artists pull together. And I just show you a very nice news because this was really a case vignette. And these a gentleman here from the UK was saying Next, um it's is, um may have up saved my life that I'm going to show you here The picture here where you perform at night be so I'm not sure if any IV was not also something to be accounted for. We propose I don't have to a time to go into detail. We have recently proposed some importance of information that in the studies we should have, like the daughter mask Mass. Don't must ask that I alluded to also the mask on time. How many hours are community? Also, the therapies rotation and also the time, too information is important. Let me go through my algorithm that are suggesting to move from a conventional oxygen too high flow and then to wean outflow and then make the patients ago to recover in another facility and also important leasing the user off prone positioning. So for carrying out I Flonase. Oh, cannula. You can use theosophy will systems, but it can also use portable Um um, your tumor buying driven systems you can have also I see ventilators, and you can also have more and more offerings off home ventilators that are not provided. This is the eye off and this is Prisma. You can also have, um, also from resume it also from other companies. So what we propose to use it use to start I, Flonase or cannula when patient is a pa or two. If I write two under 3300, especially when they are on more than five liters per minute and we should start with 30 leaders and ramping up until 60 I think 60 leaders is our target. The flow should the oxygen should maintain saturation on above 93. We don't need to add more than that. And when you want to win, it's better to decrease if I or two and then when you reach, if I have to afford it and start increasing floor. So the rocks index that I I don't have the time to discuss with you it's very important to guide you about failing or not. So if you have a Roxy index above 4.5, you're in a good situation. If it's below 2.85 at two hours, it's better that you think that this therapy is going to going to file again, coming back to these early therapy of I flow. This is a study that it's now on the review and it's posted in Met Archive. They compared the early versus late situation, so 200 versus 100 to 200 of puffy. And then you can see that the early intervention as a better mortality, and it's important that you can understand that you can also escalate. When the patient has a high flow and does not respond, you can escalate to an IV. And here, Vianello So success rate off the escalation is 44 whereas from one it's 71%. Um, now let's go back to ah CPAP and and I've e set up. This is an impressive picture off a married couple in the UK that I think everybody is a wear off, and it's important that you understand the circuit modification. So these valves, a spirit orey filtering and one study that I came across is important about also out early you initiate CPAP and these early initiation also translates into a better survival. So I propose in my ordering that you start Ah, see, pop, when the patient is 100 lower than 200 CPAP you should apply to 10 centimeters of water maybe a little bit more and also titrate if I do two above 93%. So this is out, you win. And I think that, um, a CPAP is also something that you should very minds provided that you have the elm. It's available. This is a proposal with the Max Venturi system. Self pronating as I mentioned to you at the beginning, I think it's already physiologically proven, but it's important that you substantiate your treatment with some efficacy. And it's important that you treat us much as you can for 3 to 5 days. A last word about these dual therapy. So now we have devices that that can provide both I flow and CPAP. This is ah, the Armstrong Medical device. This is the buyer a spirit. This is the very famous Vioxx 60 plus and we have inclusive now some homecare devices that you can do the same. Of course, there are two basic. They don't provide a high flow, and if I do, it's not so much, but so this might be a good opportunity to start. I flow earlier on, especially when you're running out of the more advanced I flows systems and I think industries just moving so fast. We are now having a device that is providing a portable oxygen concentrated inside, and you can bring a CPAP you can bring. I flow all together. So I would like to conclude, and I think I can convince you that 90 very respiratory therapies are not really a generating by a row. So but I'm more Dysport sing aerosols far away from the patients. So the the FDA worker infection, especially if you're provided with the proper PPE, is they are not really in a high risk. It's important that you know that your noninvasive respiratory therapies can avoid intubation, and it's okay that you delight to patient as I show you a two beginning, I think, to select the right therapy, you have to be based on the fan, a type, and the patients that are non responsive to see pop about serving the trial off I flow, and I think that if the patient really responsive to CPAP, you can start with a face mask interface. Of course, if you have how much you can start with the alma because it allows you to have less leaks and a higher number off hours of use, don't forget that you can use rotating second sees double therapies. And it's important that you describe your technique and also you describe your minimum outcomes and this is my last slide. I think the experience that we had with the major Captain Tom, is really something that we should never forget. And I think it was really a pity that he could not take the vaccine it in time. So we will never walk along without him. Thank you so much.