Lung Recruitment Device for COVID-19

1. BACKGROUND During COVID-19 pandemic, although the proportion of severe or fatal cases
may vary by location, 15-30% of hospitalized patients were admitted to the intensive
care unit in Italy and China (1-4).

Pneumonia appears to be the most frequent serious manifestation of infection. In
addition to respiratory symptoms, gastrointestinal symptoms have also been reported (2,
3, 5). The symptomatic infection can range from mild to critical; but, generally, the
clinical course seems to have characteristics of slow progression from upper airway to
the lower and the other systemic organs such as cardiac muscles. Radiographic findings
include ground-glass opacities, crazy paving appearance, air space consolidation,
broncho-vascular thickening in the lesion with a slow progression up until 10-14 days
from the onset of disease (6-8).

Staff Shortage & Protection Protecting the workforce is another critical challenge. Sick
leaves or self-isolation has increased already. Caring for infected patients represents
a substantial exposure risk for ICU staffs because of high and prolonged exposure to
critically ill patients who presumably have higher viral shedding. This should be
particularly noted for physiotherapists to whom chest physiotherapy can be prescribed
more often than usual in this situation of ICU demand. On the other hand, only a limited
number of physiotherapists are available in most of ICUs.

Airway obstruction due to the production of secretion particularly with respiratory
muscle weakness in critically ill is a major problem in clinical management. CPT has
been proposed to assist in the clearance of tracheobronchial secretions. Techniques such
as the conventional CPT with chest percussion and vibration, chest shaking and directed
coughing may help to mobilize secretions towards the trachea and trigger coughing that
could help to remove the secretions. However, a recent systematic review reported that
there is no sufficient evidence to provide CPT in routine practice with a significant
heterogeneity of the procedure techniques used (9-13).

Extra-thoracic non-invasive oscillating devices (NIOD) are designed to interrupt the
expiratory airflow and can help to secretions clearance. NIOD requires less patient
cooperation and could be used without interruptions such as due to coughing or
suctioning of secretion. Frequencer® (Dymedso, Montreal Canada) is a NIOD that locally
target the affected lung areas. The safety has been attested particularly in patients
with cystic fibrosis. In addition, this NIOD can be easily administered by
non-specialized personnel such as respiratory therapists or registered nurses (14, 15).

This proposed study is to compare the effectiveness of NIOD performed by non-specialized
personnel (respiratory therapist, nurse, physicians) versus standard CPT performed by a
physiotherapist.

2. OBJECTIVES & RESEARCH QUESTIONS Objectives

This project has 3 specific objectives:

1. To study the feasibility and tolerance of NIOD in the mechanically ventilated patients

2. To study if NIOD performed by non-specialized personnel is not inferior to the standard
CPT done by the physiotherapist in the care of COVID-19.

3. To study the impact of NIOD and CPT on oxygenation. Research questions to be asked

1. Is the NIOD safe and well-tolerated to be applied to critically ill patients with
COVID-19? 2. Is the NIOD not inferior to standard CPT performed by a physiotherapist with
respect to the effect of oxygenation in critically ill COVID-19 patients? 3. What kinds of
physiological positive effects can the NIOD and CPT provide on critically ill patients with
COVID-19? 3. SIGNIFICANCE This study will provide valuable knowledge about secretion
management in critically ill patients. It will also contribute to more efficient health care
practice and resource utilization (i.e., physiotherapist).

To be specific, NIOD could improve the respiratory management of patients with COVID-19. The
findings acquired in this study can be generalizable to other hospitals and cohorts in ICUs.
Ultimately, this could reduce the impact of COVID-19 on the health system and could reduce
the exposure of physiotherapists to COVID-19.

4. METHODS 4.1 Study Design The investigators will adopt a prospective crossover
non-inferiority randomized design.

4.2 Setting Two ICUs in CHU Sainte Justine (Pediatric ICU) and Montreal General (Adult ICU)
Hospital.

4.3 Screening of Eligible Patients and Informed Consent Procedure. When there is a
potentially eligible patient, a research assistant will be notified in 24/7 during the study
period. The investigators will obtain the informed consent (IC) from patients or
parents/guardians using an informed consent form.

4.4 Eligible Patients Please see the other section of this application. 4.5 Intervention:
Each subject will receive the NIOD (i.e., Frequencer) and the standardized CPT for this
study.

4.5.1 Suctioning and Other Interventions As per each ICU's protocol, the participants will
have a suction of secretion as needed. Any other potential interventions such as nebulization
of hypertonic saline and bronchodilator and that with a metered-dose inhaler (MDI) can be
given without any restrictions.

4.5.2 Positioning All the procedures (i.e., NIOD and CPT) will be applied with any
positioning such as sitting and prone positions. Caregivers can also change the positioning
as needed during the procedures. All the outcome parameters should be measured (before and
after the procedures) with the same positioning.

4.5.3 Detailed Procedure NIOD will be implemented on four different parts of the chest walls,
3 minutes for each part and 12 minutes in total per each session. Left and right front and
posterior chest walls will be stimulated, particularly, on the anterior chest, intercostal
spaces 1-2 above nipple line and lateral side of the mid-clavicular line 1-2 below
intercostal spaces. The intensity of the NIOD can be selected between 80-100%, which is
pre-specified on the machine. The step-by-step procedure is described in the Appendix.

4.5.4 Selection of the Membrane There are several selections of the membrane available. The
investigators will use the membrane according to the manual provided by the manufacture.

4.5.5 Standardization of the Procedure. The procedure using the NIOD will be standardized.
The investigators will use a video clip (i.e., YouTube) and will ask each caregiver to view
at least once before the first procedure of the day.

4.5.6 CPT. CPT will be defined as an assistant strike to the chest wall repeatedly with a
cupped hand in specific places. CPT will be performed by a physiotherapist as per protocol in
each institution.

4.6 Detailed Protocol Patients satisfying the eligibility criteria will have their baseline
data collected prior to the intervention.

Randomization Participants will be randomized into one of the 2 arms (NIOD first or CPT
first). In the existing studies targeting adults, 20-60Hz are most widely used (personal
communication with Dymedso Inc.). The investigators will apply 40Hz. Randomization will be
carried out by the independent research assistant in CHU Sainte Justine (CHUSJ). Random
allocation will be generated by an independent investigator in an equal number assigned to
each intervention. Stratification will be applied for age (>18 years or =<18 years of age)
and sites (CHUSJ and General Hospital) (Figure2).

Timing of the Data Measurement The data measured in mechanical ventilation and patients
monitor will be collected 1) right before the intervention being initiated, 2) 10 minutes
after the end of the intervention, and 3) 30 min after each intervention finished. The
investigators will manually record the following variables for the three timings (4.9.1).
Vital sign values including EtCO2 waveforms from the beginning of the intervention until 30
min after the intervention will be extracted from the Electronic Medical Records (i.e., every
minute) for the cohorts in CHUSJ.

4.7 Sample Size Calculation A trial aims to determine whether NIOD will be able to provide an
improvement of oxygenation not inferior to standard CPT. The investigators estimate the mean
improvement of SF ratio is 30 with a variance of 10 in CPT. It was claimed to be clinically
non-inferior if effect of NIOD was 20% lower than the standard CPT. The largest clinically
acceptable difference of 6 (30*0.20) is declared that NIOD is non-inferior compares with CPT.
Type I, II error and ratio are set at 0.05, 0.1, and 1:1. With this, we require 32 cases in
total (16 cases per group). Considering this, we will collect 25 cases per group (16-21).

4.8 Protocol Violation. Protocol violation in eligibility is defined as when a patient was
randomized but does not follow the protocol. These patients will be excluded from the
analyses. Patients who withdraw their consent after randomization will be excluded from the
analyses. The number of excluded patients after randomization will be displayed in the
CONSORT flow diagram (Fig3). Patients assigned to both arm receive the standard ICU care in
each center.

4.9 Statistical Analyses The main analysis will be performed according to the
intention-to-treat (ITT) principle. A patient who withdrew consent or patients with a
protocol violation concerning eligibility are excluded from ITT analyses. Differences in
patient characteristics between patients lost to follow-up and included patients will be
assessed. In view of the non-inferiority study design, per-protocol (PP) analyses will also
be performed. All subjects from the ITT population without protocol violations and deviations
regarding treatment will be included in the PP population. The investigators will also repeat
the analyses with logistic regression to consider that randomization was stratified by the
participating center and age (>18 or =<18 years of age). Non-inferiority will be established
if the lower limit of the one-sided 95% confidence for the mean of SF ratio for CPT group
relative to that of patients with NIOD exceeds the critical value corresponding to the
absolute 5% margin below the observed proportion under usual care. All statistical analyses
will be conducted with Stata (Stata Corp LP, TX USA) or other statistical software(s).

5. ETHICAL CONSIDERATIONS 5.1 Overview The device and membrane for adults applied have been
certified and approved by Health Canada and commercially available in Canada (Fig1a).
Although the prototype transducer for infants (Fig1b) has not been tested on patients as a
large trial, the mechanism of the pressure delivery and the intensity of the delivering
pressure/ oscillation should be similar as compared to the existing model for children and
adult patients. The devices have been approved by Health Canada. The investigators believe
there should be no excessive harm as compared to the current standard CPT. Patients will also
receive standard CPT during the study period, which is widely accepted as a practice for
airway clearance in the ICUs.

This study will be approved by the Health Research Ethics Board of the University of
Montreal, Canada. The study protocol will be registered into https://clinicaltrials.gov/ once
it is approved by the local IRB.

5.2 Risk Minimization and Data and Safety Monitoring Board (DSMB) It has shown that NIOD was
feasible and well-tolerated in adult and relatively older children. For this study, another
DSMB will be in place to independently supervise any potential side effects. It will include
Francois Proulx MD and Tse Man Sze MD. The DSMB will follow the study completion and review
any significant potential complications related to the intervention with NIOD. Any occurrence
of pneumothorax, need for unplanned intubation, life-threatening event, during or in the 2
hours following the study, will be declared to and reviewed by the DSMB, which will
independently decide on the need to stop or continue the study.