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This includes a small study of patients with bacterial pneumonia Leung and an abstract regarding particulate dispersal by volunteers Roberts One case series from China suggested that HFNC was associated with higher rates of survival than either noninvasive or invasive ventilation of course, this could reflect its use in less sick patients Yang et al, see table 2.
A management strategy for COVID by a French group used HFNC preferentially, instead of BiPAP Bouadma et al. Westafer et al. CPAP could have major advantages here: CPAP can provide the greatest amount of mean airway pressure, and thus most effective recruitment.
CPAP doesn't augment tidal volumes, so this could facilitate more lung-protective ventilation. Possible approach to CPAP therapy in COVID Increase the CPAP pressure to cm if tolerated.
Titrate FiO2 against oxygen saturation. Falling FiO2 requirements indicate effective recruitment, whereas rising FiO2 requirements suggest CPAP failure.
Further discussion of CPAP in COVID BiPAP could provide benefit beyond CPAP by providing some mechanical support for the work of breathing.
However, this does carry a theoretical risk of possibly encouraging the patient to take excessively large breaths thereby inducing lung damage.
The ideal BiPAP settings probably involve using a high level of end-expiratory pressure with a low driving pressure e. This will closely resemble CPAP, with a little added support.
BiPAP could be particularly useful in patients with combined syndromes e. COPD plus COVID There is a decreased risk of aspiration if emesis occurs.
In one RCT investigating ARDS, the helmet reduced intubation rates and possibly mortality Patel The helmet can be set up without requiring a ventilator, thereby potentially sparing ventilators for other patients.
Helmets have previously not been used in the United States, but they have become available currently. The low compliance of the helmet interface may make it difficult to synchronize with the patient when performing BiPAP.
Thus, these devices might work a bit better with CPAP. A discussion of how to configure this is located here. This is possible with either a two-limb system involving a full featured mechanical ventilator, or a one-limb system involving a dedicated BiPAP machine e.
Respironics V Improved mask seal may improve safety. Helmet masks might theoretically have an advantage here. For patients with difficult lying in a prone position, alternating between lying on different sides might also be beneficial.
Can be combined with simultaneous use of any other noninvasive support device e. Requires cooperative patient with intact mentation. Could be useful especially in situations where access to invasive ventilation is limited.
Same physiology as proning a patient who is intubated proning is proning. For example: May improve secretion clearance. May recruit atelectatic lung tissue in the dependent lung basis this seems to be a major issue in COVID patients.
Proning intubated patients with COVID is widely reported to be successful in improving oxygenation. It stands to reason that similar success could be obtained by proning a patient who isn't intubated.
Awake proning was recommended by Sun et al. For patients with difficulty maintaining this position, other positions may be used e.
The most important aspect might be to avoid spending considerable time in a supine position which promotes atelectasis.
Make sure support devices are well secured to the patient e. Follow oxygenation and FiO2 requirement. Ideally an improvement in oxygenation should be seen within a few hours.
If no change in oxygenation is observed, ongoing pronation may have less merit. These don't appear to be evidence-based or guideline-supported.
Patients vary widely, so use common sense. Patients who can avoid intubation have a substantially better prognosis than patients who are intubated.
Although this obviously doesn't prove causality, it does suggest that intubation should be avoided whenever possible. Ultimately, the decision to intubate is based on the clinical judgement of the bedside practitioner.
Key factors to consider in this decision may include: 1 Oxygenation There is no well-defined oxygen saturation trigger for intubation.
Tachypnea without increased work of breathing is less concerning. Increased work of breathing e.
Ongoing decline over time may favor intubation. However, since this definition is extremely broad, meeting it doesn't have any specific clinical implication.
COVID patients may respond favorably to positive airway pressure e. PseudoARDS is clinically relevant because these patients are less likely to benefit from proning.
Prone ventilation does appear to work well for patients with COVID, but it may increase requirements for sedation and paralytics thereby potentially extending time on the ventilator.
Benefits of APRV include: 1 A primary physiologic problem in COVID appears to be de-recruitment, which is well managed by APRV.
This may avoid iatrogenic complications from these interventions e. This may allow us to render patients comfortable and awake on the ventilator more easily, while using fewer medications an especially important challenge as we run out of many sedatives.
APRV initiation can cause hemodynamic shifts, so pay careful attention to blood pressure during initiation. True failure to respond to APRV within hours e.
However, when started early APRV may be more likely to succeed — thereby avoiding the need for proning.
The main limitation to APRV is that many centers aren't familiar with it or don't have ventilators which can provide APRV. There is no consensus regarding exactly how to titrate PEEP.
ARDSnet PEEP tables may represent a reasonable starting point. Titration to clinical effect may be useful if there is sufficient time and experience to do this.
The concept of using unusually low levels of PEEP does not appear to be evidence-based and is not recommended for COVID. Low levels of PEEP may cause partial atelectasis of the lungs, leading to atelectotrauma repeated opening and closing of the alveoli with each respiratory cycle.
Substantial atelectotrauma may be even more dangerous than barotrauma. Targeting a mildly elevated serum bicarbonate can facilitate safe ventilation with low tidal volumes more on different forms of IV bicarbonate here.
For failure to respond to initial ventilator optimization e. Proning is effective at increasing oxygenation, but it has the drawback of requiring deeper levels of sedation.
Paralysis may be needed, but many patients can tolerate proning without paralysis simply with deep sedation. Increasing levels of sedation with or without paralysis may increase the risk of delirium and myopathy, potentially prolonging the length of ventilation.
Potential indications: 1 Refractory hypoxemia 2 Hemodynamic instability with evidence of cor pulmonale e. Blog exploring the general strategy to setting the ventilators here.
Columbia Presbyterian protocol for splitting ventilators here. Some additional ideas about how to hook everything up here. It could be concievable to connect outpatient BiPAP machines to endotracheal tubes.
This would require the patient to spontaneously trigger breaths, so light sedation would be needed. Compared to the split ventilator technique above , BiPAP devices could be used with less ill patients: Splitting the ventilator requires deep sedation and provides full ventilator support — this is better for the sickest patients.
BiPAP machines require light sedation and provides partial support — this could be used for less ill patients. Home-design BiPAP masks are often unable to generate high flow rates, so they won't be able to support patients who are dyspneic with high flow demands.
On a related note, Trilogy devices could probably easily be repurposed to be used as ventilators. Relatively inexpensive and there still seems to be a reasonable supply available.
Allows for delivering titratable levels of PEEP. EMCrit page on the oxylator here. In some ways, they may be conceptualized as a simplified and primitive version of an oxylator resuscitator.
They are designed for field use in a disaster. Different strategies may work for different types of patients.
Any way that we can free up ventilators is beneficial. Unfortunately, they may continue to have a tendency to de-recruit their lungs.
Consequently, there may be an increased risk of deterioration after extubation. Overall it seems that patients with COVID can be weaned off ventilation similarly to other patients, with the exception that post-extubation BiPAP might be a stronger consideration.
CPAP therapy or BiPAP with high end-expiratory pressure might be useful to prevent de-recruitment in these patients.
By the time of extubation, patients will often have been ill for well over a week. It's likely that their viral load will be decreasing at that point, so the risk of virus transmission may be lower compared to the initial intubation.
More on transmission above. It tends to be a late finding, occurring weeks after admission. Complement deposition in the tubules was observed in six patients within an autopsy study, raising the question of whether this may be a contributory mechanism.
Diao B et al. Virus can bind to proximal tubular epithelial cells which express the ACE2 receptor , so direct viral infection is possible.
Re-dose renally cleared medications. Hemodialysis indications seem to be the same as for other patients. The prognosis of patients requiring dialysis appears poor.
In multivariable analysis, renal failure was the strongest predictor of mortality more-so even than ARDS Chu et al.
Goals of care should be explored prior to proceeding to hemodialysis. Avoid giving excess fluid, as this may necessitate dialysis to remove fluid.
COVID patients may be hyper-coagulable, so heparin or citrate anticoagulation anticoagulation may be important to maintain a CRRT circuit.
When in doubt, it may be sensible to obtain bacterial cultures, prior to initiation of empiric antibiotic therapy. This will generally be initiated initially, for coverage of possible bacterial pneumonia.
MRSA coverage? COVID doesn't seem to increase the risk of MRSA unlike influenza. This based on anecdotal reports, with a very low level of evidence.
MRSA therapy could be instituted based on typical indications for a patient with community-acquired pneumonia further discussion here and here. Excessive use of vancomycin should be discouraged, as patients are at substantial risk of developing renal failure.
COVID associated coagulopathy back to contents pathophysiology COVID produces a hyper-coagulable state, for several reasons: 1 Inflammation e. IL-6 stimulates up-regulation of fibrinogen synthesis by the liver.
Carty 2 Virus infects endothelial cells. COVID-associated coagulopathy CAC has some similarities to disseminated intravascular coagulation DIC.
However, CAC appears to be a distinct entity from DIC. The pathophysiological hallmark of DIC is systemic coagulation activation, which generally seems to be lacking in CAC e.
The primary consequence of CAC appears to be thrombosis. Microthrombi may contribute to organ dysfunction especially ARDS. Macrovascular thrombosis often leads to deep vein thrombosis and pulmonary emboli.
Zhou et al. Fibrinogen : In clinical practice, fibrinogen is generally elevated or normal. Some reports describe extremely severely ill patients with hypofibrinogenemia.
However, it's possible that some of these patients may have been suffering from superimposed bacterial pneumonia leading to DIC. Han et al.
PT and INR is often slightly elevated. Markedly elevated Factor VIII levels may tend to pull the aPTT downwards.
Thromboelastography TEG Panigada et al. Antithrombin levels may be slightly diminished. Factor VIII and von Willebrand factor are considerably increased.
CT pulmonary angiography May be useful in select patients. Logistically, large-volume CT scanning of patients with COVID is often impossible e.
In ICU patients, this is a very common problem. For patients on a heparin infusion, heparin resistance will be clinically obvious due to inability to achieve a therapeutic PTT level or an anti-Xa level.
For some clubs who have failed to win immediate promotion back to the Premier League, financial problems, including in some cases administration or even liquidation have followed.
Further relegations down the footballing ladder have ensued for several clubs unable to cope with the gap. As of the —18 season, Premier League football has been played in 58 stadiums since the formation of the division.
As a result, all stadiums in the Premier League are all-seater. The stadiums for the —18 season show a large disparity in capacity.
For example, Wembley Stadium , the temporary home of Tottenham Hotspur, has a capacity of 90, while Dean Court , the home of Bournemouth , has a capacity of 11, Stadium attendances are a significant source of regular income for Premier League clubs.
Managers in the Premier League are involved in the day-to-day running of the team, including the training, team selection and player acquisition.
Their influence varies from club-to-club and is related to the ownership of the club and the relationship of the manager with fans.
Several caretaker managers have gone on to secure a permanent managerial post after performing well as a caretaker, including Paul Hart at Portsmouth and David Pleat at Tottenham Hotspur.
He broke the record set by Alex Ferguson , who had managed matches with Manchester United from the Premier League's inception to his retirement at the end of the —13 season.
Ferguson was in charge of Manchester United from November until his retirement at the end of the —13 season, meaning he was manager for the last five years of the old Football League First Division and all of the first 21 seasons of the Premier League.
There have been several studies into the reasoning behind, and effects of, managerial sackings. Bas ter Weel of the University of Amsterdam , performed two separate studies which helped to explain the statistics behind managerial sackings.
Bridgewater's study found clubs generally sack their managers upon dropping below an average of one point per match.
At the inception of the Premier League in —93 , just 11 players named in the starting line-ups for the first round of matches hailed from outside of the United Kingdom or Ireland.
On 26 December , Chelsea became the first Premier League side to field an entirely foreign starting line-up,  and on 14 February , Arsenal were the first to name a completely foreign man squad for a match.
In response to concerns that clubs were increasingly passing over young English players in favour of foreign players, in , the Home Office tightened its rules for granting work permits to players from countries outside of the European Union.
If a player does not meet those criteria, the club wishing to sign him may appeal. Players may only be transferred during transfer windows that are set by the Football Association.
The two transfer windows run from the last day of the season to 31 August and from 31 December to 31 January.
Player registrations cannot be exchanged outside these windows except under specific licence from the FA, usually on an emergency basis.
There is no team or individual salary cap in the Premier League. The ratio of the wages of the highest paid team to lowest paid in the Premier League is 6.
This is much lower than in La Liga Because of the lower differential between team wage bills in the Premier League, it is often regarded as being more competitive than other top European leagues.
The record transfer fee for a Premier League player has risen steadily over the lifetime of the competition. Italics denotes players still playing professional football, Bold denotes players still playing in the Premier League.
The Premier League Golden Boot is awarded each season to the top scorer in the division. Andrew Cole and Alan Shearer hold the record for most goals in a season 34 — for Newcastle and Blackburn respectively.
The Premier League maintains two trophies — the genuine trophy held by the reigning champions and a spare replica.
Two trophies are held in the event that two clubs could win the League on the final day of the season. It consists of a trophy with a golden crown and a malachite plinth base.
Its main body is solid sterling silver and silver gilt , while its plinth is made of malachite, a semi-precious stone.
The plinth has a silver band around its circumference, upon which the names of the title-winning clubs are listed. Malachite's green colour is also representative of the green field of play.
Two of the lions are found above the handles on either side of the trophy — the third is symbolised by the captain of the title-winning team as he raises the trophy, and its gold crown, above his head at the end of the season.
In , a special gold version of the trophy was commissioned to commemorate Arsenal winning the title without a single defeat.
In addition to the winner's trophy and the individual winner's medals awarded to players who win the title, the Premier League also issues other awards throughout the season.
A man of the match award is awarded to the player who has the greatest impact in an individual match. The Golden Boot award is given to the top goalscorer of every season, The Playmaker of the Season award is given to the player who make the most assists of every season  and the Golden Glove award is given to the goalkeeper with the most clean sheets at the end of the season.
From the —18 season , players also receive a milestone award for appearances and every century there after and also players who score 50 goals and multiples thereof.
Each player to reach these milestones will receive a presentation box from the Premier League containing a special medallion and a plaque commemorating their achievement.
In , the Premier League celebrated its second decade by holding the 20 Seasons Awards: . From Wikipedia, the free encyclopedia.
Redirected from English Premier League. This article is about the English association football league.
For other uses, see Premier League disambiguation. Association football league in England. See also: Foundation of the Premier League.
See also: List of Premier League seasons. Main article: List of Premier League clubs. See also: List of English football champions. Aston Villa.
Leicester City. Manchester City. Man- chester United. Norwich City. Sheffield United. Crystal Palace.
West Ham United. See also: List of association football clubs playing in the league of another country. See also: UEFA country coefficients.
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Bereits vor der Qualifikation stand fest, dass Frankreich als Weltmeister sowie Deutschland und Dänemark als Gastgeber am Turnier teilnehmen werden.
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Das Finale sowie die dänischen Vorrundenspiele werden im dänischen Herning stattfinden. Eine andere Möglichkeit bietet der Anbieter Sportdeutschland.
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November Neu im Blog. Fernsehen und Streaming in der Zukunft: 5G als Schlüssel? Unser Newsletter Ich akzeptiere die Datenschutzerklärung.
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