Abstract
Background:Lung-protective ventilation is key in bridging patients suffering from COVID-19 acute respiratory distress syndrome (ARDS) to recovery. However, resource and personnel limitations during pandemics complicate the implementation of lung-protective protocols. Automated ventilation modes may prove decisive in these settings enabling higher degrees of lung-protective ventilation than conventional modes.Method:Prospective study at a Swiss university hospital. Critically ill, mechanically ventilated COVID-19 ARDS patients were allocated, by study-blinded coordinating staff, to either closed-loop or conventional mechanical ventilation, based on mechanical ventilator availability. Primary outcome was the overall achieved percentage of lung-protective ventilation in closed-loop versus conventional mechanical ventilation, assessed minute-by-minute, during the initial 7 days and overall mechanical ventilation time. Lung-protective ventilation was defined as the combined target of tidal volume <8 ml per kg of ideal body weight, dynamic driving pressure <15 cmH2O, peak pressure <30 cmH2O, peripheral oxygen saturation ≥88% and dynamic mechanical power <17 J/min.Results:Forty COVID-19 ARDS patients, accounting for 1,048,630 minutes (728 days) of cumulative mechanical ventilation, allocated to either closed-loop (n = 23) or conventional ventilation (n = 17), presenting with a median paO2/ FiO2 ratio of 92 [72-147] mmHg and a static compliance of 18 [11-25] ml/cmH2O, were mechanically ventilated for 11 [4-25] days and had a 28-day mortality rate of 20%. During the initial 7 days of mechanical ventilation, patients in the closed-loop group were ventilated lung-protectively for 65% of the time versus 38% in the conventional group (Odds Ratio, 1.79; 95% CI, 1.76-1.82; P < 0.001) and for 45% versus 33% of overall mechanical ventilation time (Odds Ratio, 1.22; 95% CI, 1.21-1.23; P < 0.001).Conclusion:Among critically ill, mechanically ventilated COVID-19 ARDS patients during an early highpoint of the pandemic, mechanical ventilation using a closed-loop mode was associated with a higher degree of lung-protective ventilation than was conventional mechanical ventilation.
Highlights
Lung-protective ventilation is key in bridging patients suffering from COVID-19 acute respiratory distress syndrome (ARDS) to recovery
The study was approved by the cantonal ethics committee of Zurich (BASEC: 2020-01681) and informed consent was obtained from the patients or from their of kin
Patients were prospectively included in this study if they presented with (I) a SARS-CoV-2 infection that was laboratory confirmed by nucleic acid amplification according to the WHO-issued testing guidelines,[15] and (II) a critical manifestation of COVID-19 requiring admission to an intensive care unit and treatment with invasive mechanical ventilation due to profound hypoxemia, complying with the Berlin definition for ARDS.[16]
Summary
Lung-protective ventilation is key in bridging patients suffering from COVID-19 acute respiratory distress syndrome (ARDS) to recovery. Ill, mechanically ventilated COVID-19 ARDS patients were allocated, by study-blinded coordinating staff, to either closed-loop or conventional mechanical ventilation, based on mechanical ventilator availability. Conclusion: Among critically ill, mechanically ventilated COVID-19 ARDS patients during an early highpoint of the pandemic, mechanical ventilation using a closed-loop mode was associated with a higher degree of lung-protective ventilation than was conventional mechanical ventilation. Coronavirus disease 2019 (COVID-19) triggered a surge of critically ill patients with acute respiratory distress syndrome (ARDS) in need of mechanical ventilation.[1] Optimal management of ARDS mandates lung-protective mechanical ventilation so as to minimize ventilator induced lung injury (VILI) and allow for optimal recovery of the lung.[2,3,4] Due to the high number of patients, intensive care units (ICUs) worldwide have been overwhelmed, leading to a shortage in the expertise and resources needed to ensure the implementation of such lung-protective settings.[5,6,7] the incidence of VILI has risen markedly and mortalities in COVID-19 ARDS (CARDS) are reaching levels not experienced for decades in the setting of ARDS.[8,9,10].
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