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


Crit Care. 2021;25(175) 

In This Article


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.

Traditionally, the treatment of acute respiratory distress syndrome (ARDS) has focused mainly on IMV and its optimization;[1] nonetheless, in the last decade new approaches have been increasingly explored, primarily high-flow oxygen therapy by nasal cannula (HFNC) and noninvasive positive-pressure ventilation (NIV).[2,3] 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, but also to avoid endangering hospital personnel by generating aerosols with HFNC and NIV. Nonetheless, in certain areas and centers, a lack of mechanical ventilators and adequately trained ICU staff forced clinicians to use noninvasive techniques to treat CARDS.[5]

The high mortality rate associated with CARDS observed at the start to the pandemic has decreased over time.[6,7] While many factors may explain this improvement, the decision to use invasive or noninvasive respiratory support remains one of the most controversial ones.[8] Expert opinions range widely. While some eminent authors urge for early intubation at the first signs of respiratory fatigue, to prevent patient self-inflicted lung injury (P-SILI),[9–12] others argue that all noninvasive options should be exhausted before proceeding to IMV.[13–18] Nevertheless, there is a surprising lack of evidence regarding the optimal respiratory support strategy.

The present study was designed in the context of the ubiquitous uncertainty surrounding respiratory support strategies in critically ill COVID-19 patients. This study consists of a subanalysis of the data collected prospectively in the RISC-19-ICU registry.[19] The main objective was to determine which respiratory support strategy employed during the first months of the COVID-19 pandemic was associated with a better overall prognosis. To reflect the early intubation trend followed during the first months of the pandemic, patients directly intubated on ICU admission but with matched severity characteristics to the noninvasively supported patients were also included in the analysis, constituting an independent respiratory support strategy.