Feasibility and Clinical Outcomes of a Step Up Noninvasive Respiratory Support Strategy in Patients with Severe COVID-19 Pneumonia.

Silvia Coppola,Marina Saad,Laura Saderi,Michele Mondoni,Dejan Radovanovic,Giovanni Sotgiu,Alessia Gandola,Giuseppe Francesco Sferrazza Papa,Stefano Centanni,Pierachille Santus,Davide Alberto Chiumello

doi:10.3390/jcm10225444

Abstract

The best noninvasive respiratory strategy in patients with Coronavirus Disease 2019 (COVID-19) pneumonia is still discussed. We aimed at assessing the rate of endotracheal intubation (ETI) in patients treated with continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) if CPAP failed. Secondary outcomes were in-hospital mortality and in-hospital length of stay (LOS). A retrospective, observational, multicenter study was conducted in intermediate-high dependency respiratory units of two Italian university hospitals. Consecutive patients with COVID-19 treated with CPAP were enrolled. Thoraco-abdominal asynchrony or hemodynamic instability led to ETI. Patients showing SpO2 ≤ 94%, respiratory rate ≥ 30 bpm or accessory muscle activation on CPAP received NIV. Respiratory distress and desaturation despite NIV eventually led to ETI. 156 patients were included. The overall rate of ETI was 30%, mortality 18% and median LOS 24 (17–32) days. Among patients that failed CPAP (n = 63), 28% were intubated, while the remaining 72% received NIV, of which 65% were intubated. Patients intubated after CPAP showed lower baseline PaO2/FiO2, lower lymphocyte counts and higher D-dimer values compared with patients intubated after CPAP + NIV. Mortality was 22% with CPAP + ETI, and 20% with CPAP + NIV + ETI. In the case of CPAP failure, a NIV trial appears feasible, does not deteriorate respiratory status and may reduce the need for ETI in COVID-19 patients.

Highlights

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by a new pathogen named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
Of patients that failed both continuous positive airway pressure (CPAP) and the subsequent NIV trial, (2) NIV avoided intubation in 35% of patients that failed CPAP; (3) overall in-hospital mortality was 18%: in patients that failed CPAP and were intubated mortality was 22%, while it was 20% in those treated with a NIV trial, and (4) length of hospital stay was similar in patients that succeeded or failed CPAP or NIV
The majority of COVID-19 patients with acute hypoxemic respiratory failure can be managed with noninvasive respiratory support without the need for immediate endotracheal intubation (ETI)

Summary

Introduction

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by a new pathogen named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Acute respiratory failure and acute respiratory distress syndrome (ARDS) caused by bilateral interstitial pneumonia are some of the most severe complications of COVID-19 [1,2]. Patients with respiratory failure frequently experience hypoxemia, increased respiratory rate and inspiratory effort [6]. Respiratory support should reduce the inspiratory effort and the pulmonary stress (i.e., patient self-inflicted lung injury) [10,11,12]. Based on the severity of acute respiratory failure, the respiratory support can include high flow oxygen therapy, continuous positive airway pressure (CPAP), noninvasive (NIV) and invasive mechanical ventilation (IMV) [6]. European consensus statements for the management of non-critically ill COVID-19 patients with acute respiratory failure recommended Helmet

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