Implications of Early Respiratory Support Strategies on Disease Progression in Critical COVID-19

A Matched Subanalysis of the Prospective RISC-19-ICU Cohort

Pedro D. Wendel Garcia; Hernán Aguirre-Bermeo; Philipp K. Buehler; Mario Alfaro-Farias; Bernd Yuen; Sascha David; Thomas Tschoellitsch; Tobias Wengenmayer; Anita Korsos; Alberto Fogagnolo; Gian-Reto Kleger; Maddalena A. Wu; Riccardo Colombo; Fabrizio Turrini; Antonella Potalivo; Emanuele Rezoagli; Raquel Rodríguez-Garcia; Pedro Castro; Arantxa Lander-Azcona; Maria C. Martín-Delgado; Herminia Lozano-Gómez; Rolf Ensner; Marc P. Michot; Nadine Gehring; Peter Schott; Martin Siegemund; Lukas Merki; Jan Wiegand; Marie M. Jeitziner; Marcus Laube; Petra Salomon; Frank Hillgaertner; Alexander Dullenkopf; Hatem Ksouri; Sara Cereghetti; Serge Grazioli; Christian Bürkle; Julien Marrel; Isabelle Fleisch; Marie-Helene Perez; Anja Baltussen Weber; Samuele Ceruti; Katharina Marquardt; Tobias Hübner; Hermann Redecker; Michael Studhalter; Michael Stephan; Daniela Selz; Urs Pietsch; Anette Ristic; Antje Heise; Friederike Meyer zu Bentrup; Marilene Franchitti Laurent; Patricia Fodor; Tomislav Gaspert; Christoph Haberthuer; Elif Colak; Dorothea M. Heuberger; Thierry Fumeaux; Jonathan Montomoli; Philippe Guerci; Reto A. Schuepbach; Matthias P. Hilty; Ferran Roche-Campoon

Disclosures

Crit Care. 2021;25(175) 

In This Article

Abstract and Introduction

Abstract

Background: Uncertainty 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.

Methods: Subanalysis 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.

Results: Initially, 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).

Conclusion: In 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.

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