High Incidence of Barotrauma in Patients With Severe Coronavirus Disease 2019.

Michael R Kahn,Joseph Isaac Wong,Richard L Watson,Jay T Thetford,Nader Kamangar

doi:10.1177/0885066621989959

Abstract

Objective.:To report the high incidence of barotrauma in critically ill patients admitted to the intensive care unit (ICU) with coronavirus disease 2019 (COVID-19) and to discuss its implications.Design.:Retrospective cohort study.Setting.:ICU of an academic county hospital in Los Angeles, CA admitted from March 15-June 20, 2020.Patients.:77 patients with COVID-19 pneumonia. 75 patients met inclusion criteria.Results.:21% of patients with severe COVID-19 sustained barotrauma (33% of patients receiving IMV, 8% of patients receiving (NIV). There were no differences between the barotrauma and non-barotrauma groups regarding demographics, illness severity, or medications received, nor tidal volume or average/peak airway pressures in those receiving IMV. In the barotrauma group there was a greater proportion of patients receiving therapeutic anticoagulation (81% vs. 47%, p = 0.023) and ventilated using airway pressure release ventilation mode (13% vs. 0%, p = 0.043). Barotrauma was associated with increased likelihood of receiving a tracheostomy (OR 2.58 [0.23-4.9], p = 0.018]), longer median ICU length of stay (17 days vs. 7 days, p = 0.03), and longer median length of hospitalization (26 days vs. 14 days, p < 0.001). There was also a trend toward prolonged median duration of IMV (12.5 days vs 7 days, p = 0.13) and higher average mortality (56% vs 37%, p = 0.25).Conclusions.:Barotrauma is seen in 5-12% of patients with ARDS receiving IMV and is exceedingly rare in patients receiving NIV. We report a high incidence of barotrauma observed in critically ill patients with COVID-19 requiring either NIV or IMV. While there was a trend toward increased mortality in patients with barotrauma, this did not reach statistical significance. The increased incidence of barotrauma with COVID-19 may be a product of the pathophysiology of this disease state and a heightened inflammatory response causing rampant acute lung injury. Evidence-based medicine and lung-protective ventilation should remain the mainstay of treatment.

Highlights

The search for effective treatments for coronavirus disease 2019 (COVID-19) has become a priority in the medical community since the pandemic began
Barotrauma was seen in 30% of patients receiving invasive mechanical ventilation (IMV) diagnosed with Middle East Respiratory Syndrome coronavirus (MERS-CoV), 44% of patients treated for influenza A H7N9 (H7N9), and 8% of patients treated for influenza A H1N1 (H1N1).[20,21]. In this single center study, we examine a large sample of critically ill patients in order to better characterize the incidence of barotrauma in patients with COVID-19 respiratory failure, identify the risk factors associated with barotrauma, and determine its impact on patient mortality and length of hospital stay
Between March 15 and June 20 of 2020, 77 patients were admitted to the intensive care unit (ICU) with COVID-19, 75 of whom met Incidence of Barotrauma Sustained in CriƟcally Ill COVID-19 PaƟents

Summary

Introduction

The search for effective treatments for coronavirus disease 2019 (COVID-19) has become a priority in the medical community since the pandemic began. Invasive mechanical ventilation (IMV) continues to be a mainstay of treatment for severe respiratory failure. Despite novel therapies and lung-protective ventilation, mortality remains high for patients requiring IMV, often due to complications from sedation, nosocomial infections, and barotrauma.[1,2,3] The high mortality associated with each of these risks makes understanding the sequelae of severe COVID-19 in the critical care setting all the more important.[4,5,6]. Barotrauma, defined as the presence of air outside the pleural surface of the lung, is a known complication of the acute respiratory distress syndrome (ARDS), occurring in 8-11% of all cases.[6,7,8,9,10,11] Since the development of the ARDSnet protocol, low tidal volume ventilation at 6-8cc/kg based on ideal body weight (IBW) has reduced these rates to 5-8%.8-11

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Discussion

Conclusion