Abstract
BackgroundUncertainty about the optimal respiratory support strategies in critically ill COVID-19 patients is widespread. While the risks and benefits of noninvasive techniques versus early invasive mechanical ventilation (IMV) are intensely debated, actual evidence is lacking. We sought to assess the risks and benefits of different respiratory support strategies, employed in intensive care units during the first months of the COVID-19 pandemic on intubation and intensive care unit (ICU) mortality rates.MethodsSubanalysis of a prospective, multinational registry of critically ill COVID-19 patients. Patients were subclassified into standard oxygen therapy ≥10 L/min (SOT), high-flow oxygen therapy (HFNC), noninvasive positive-pressure ventilation (NIV), and early IMV, according to the respiratory support strategy employed at the day of admission to ICU. Propensity score matching was performed to ensure comparability between groups.ResultsInitially, 1421 patients were assessed for possible study inclusion. Of these, 351 patients (85 SOT, 87 HFNC, 87 NIV, and 92 IMV) remained eligible for full analysis after propensity score matching. 55% of patients initially receiving noninvasive respiratory support required IMV. The intubation rate was lower in patients initially ventilated with HFNC and NIV compared to those who received SOT (SOT: 64%, HFNC: 52%, NIV: 49%, p = 0.025). Compared to the other respiratory support strategies, NIV was associated with a higher overall ICU mortality (SOT: 18%, HFNC: 20%, NIV: 37%, IMV: 25%, p = 0.016).ConclusionIn this cohort of critically ill patients with COVID-19, a trial of HFNC appeared to be the most balanced initial respiratory support strategy, given the reduced intubation rate and comparable ICU mortality rate. Nonetheless, considering the uncertainty and stress associated with the COVID-19 pandemic, SOT and early IMV represented safe initial respiratory support strategies. The presented findings, in agreement with classic ARDS literature, suggest that NIV should be avoided whenever possible due to the elevated ICU mortality risk.
Highlights
Uncertainty about the optimal respiratory support strategies in critically ill COVID-19 patients is wide‐ spread
The intubation rate was lower in patients initially ventilated with high-flow oxygen therapy by nasal cannula (HFNC) and noninvasive positive-pressure ventilation (NIV) compared to those who received standard oxygen therapy (SOT) (SOT: 64%, HFNC: 52%, NIV: 49%, p = 0.025)
Compared to the other respiratory support strategies, NIV was associated with a higher overall intensive care unit (ICU) mortality (SOT: 18%, HFNC: 20%, NIV: 37%, invasive mechanical ventilation (IMV): 25%, p = 0.016)
Summary
Uncertainty about the optimal respiratory support strategies in critically ill COVID-19 patients is wide‐ spread. While the risks and benefits of noninvasive techniques versus early invasive mechanical ventilation (IMV) are intensely debated, actual evidence is lacking. Coronavirus disease 2019 (COVID-19) has generated a surge of critically ill patients who require invasive mechanical ventilation (IMV) overburdening intensive care units (ICU) worldwide. At the onset of the COVID-19 pandemic, most clinicians supported by the recommendations of international guidelines employed either standard oxygen therapy (SOT) or early IMV for the treatment of COVID-19-induced ARDS (CARDS) [4]. This choice was probably influenced by the numerous uncertainties regarding the new pathology, and to avoid endangering hospital personnel by generating aerosols with HFNC and NIV. There is a surprising lack of evidence regarding the optimal respiratory support strategy
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have