Respiratory Support Techniques for COVID-19-Related ARDS in a Sub-Saharan African Country: A Multicenter Observational Study

Abstract

Limited data from low-income countries report on respiratory support techniques in COVID-19-associated ARDS. Which respiratory support techniques are used in patients with COVID-19-associated ARDS in Uganda? A multicenter, prospective, observational study was conducted at 13 Ugandan hospitals during the pandemic and included adults with COVID-19-associated ARDS. Patient characteristics, clinical and laboratory data, initial and most advanced respiratory support techniques, and 28-day mortality were recorded. Standard tests, log-rank tests, and logistic regression analyses were used for statistical analyses. Four hundred ninety-nine patients with COVID-19-associated ARDS (mild, n= 137; moderate, n= 247; and severe, n= 115) were included (ICU admission, 38.9%). Standard oxygen therapy (SOX), high-flow nasal oxygen (HFNO), CPAP, noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) was used as the first-line (most advanced) respiratory support technique in 37.3%(35.3%), 10%(9.4%), 11.6%(4.8%), 23.4%(14.4%), and 17.6%(36.6%) of patients, respectively. The first-line respiratory support technique was escalated in 19.8%of patients. Twenty-eight-day mortality was 51.9%(mild ARDS, 13.1%; moderate ARDS, 62.3%; severe ARDS, 75.7%; P< .001) and was associated with respiratory support techniques as follows: SOX, 19.9%; HFNO, 31.9%; CPAP, 58.3%; NIV 61.1%; and IMV, 83.9%(P< .001). Proning was used in 79 patients (15.8%; 59 of 79 awake) and was associated with lower mortality (40.5%vs54%; P= .03). The oxygen saturation to Fio2 ratio (OR, 0.99; 95%CI, 0.98-0.99; P< .001) and respiratory rate (OR, 1.07; 95%CI, 1.03-1.12; P= .002) at admission and NIV (OR, 6.31; 95%CI, 2.29-17.37; P< .001) or IMV (OR, 8.08; 95%CI, 3.52-18.57; P< .001) use were independent risk factors for death. SOX, HFNO, CPAP, NIV, and IMV were used as respiratory support techniques in patients with COVID-19-associated ARDS in Uganda. Although these data are observational, they suggest that the use of SOX and HFNO therapy as well as awake proning are associated with a lower mortality resulting from COVID-19-associated ARDS in a resource-limited setting.