Abstract
Invasive mechanical ventilation (IMV) is the standard treatment in critically ill COVID-19 patients with acute severe respiratory distress syndrome (ARDS). When IMV setting is extremely aggressive, especially through the application of high positive-end-expiratory respiration (PEEP) values, lung damage can occur. Until today, in COVID-19 patients, two types of ARDS were identified (L- and H-type); for the L-type, a lower PEEP strategy was supposed to be preferred, but data are still missing. The aim of this study was to evaluate if a clinical management with lower PEEP values in critically ill L-type COVID-19 patients was safe and efficient in comparison to usual standard of care. A retrospective analysis was conducted on consecutive patients with COVID-19 ARDS admitted to the ICU and treated with IMV. Patients were treated with a lower PEEP strategy adapted to BMI: PEEP 10 cmH2O if BMI < 30 kg m−2, PEEP 12 cmH2O if BMI 30–50 kg m−2, PEEP 15 cmH2O if BMI > 50 kg m−2. Primary endpoint was the PaO2/FiO2 ratio evolution during the first 3 IMV days; secondary endpoints were to analyze ICU length of stay (LOS) and IMV length. From March 2 to January 15, 2021, 79 patients underwent IMV. Average applied PEEP was 11 ± 2.9 cmH2O for BMI < 30 kg m−2 and 16 ± 3.18 cmH2O for BMI > 30 kg m−2. During the first 24 h of IMV, patients’ PaO2/FiO2 ratio presented an improvement (p<0.001; CI 99%) that continued daily up to 72 h (p<0.001; CI 99%). Median ICU LOS was 15 days (10–28); median duration of IMV was 12 days (8–26). The ICU mortality rate was 31.6%. Lower PEEP strategy treatment in L-type COVID-19 ARDS resulted in a PaO2/FiO2 ratio persistent daily improvement during the first 72 h of IMV. A lower PEEP strategy could be beneficial in the first phase of ARDS in critically ill COVID-19 patients.
Highlights
Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) is the cause of COVID-19, a pandemic that has affected more than 180,000,000 individuals and caused nearly 4,000,000 deaths since initial detection of the virus at the end of January 2019 [1]
During acute respiratory distress syndrome (ARDS), in the setting of critically ill COVID19 patients, the PaO2/FiO2 ratio is typically used as a prognostic stratification parameter [20]; it determines lung respiratory efficiency, acting as a primary clinical indicator of hypoxemia [20], allowing to properly evaluate changes in patients’ respiratory status. The aim of this project was to verify if, in critically ill COVID-19 patients, a clinical management implementing a lower positive-endexpiratory respiration (PEEP) strategy during Invasive mechanical ventilation (IMV) was safe and efficient comparing to usual standard of care, analyzing the PaO2/FiO2 ratio
After approval by the Ethical Committee (Ethics Committees of Canton Ticino; Dec 2020, CE TI 3775) and in accordance with local federal rules, a retrospective analysis was conducted on consecutive patients with acute respiratory distress due to COVID-19 pneumonia admitted to the ICU during two pandemic waves
Summary
Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) is the cause of COVID-19, a pandemic that has affected more than 180,000,000 individuals and caused nearly 4,000,000 deaths since initial detection of the virus at the end of January 2019 [1]. Invasive mechanical ventilation (IMV) is the gold standard treatment in critically ill COVID-19 patients. With acute respiratory distress syndrome (ARDS); in this scenario, ventilatory settings with increased positive-endexpiratory respiration (PEEP) values have been suggested [2,3,4]. When IMV setting is extremely aggressive, as in the case of high PEEP values, pulmonary complications like barotrauma, volutrauma, or biotrauma can occur [5,6,7]
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