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Observational Study
. 2021 Mar 19;25(1):111.
doi: 10.1186/s13054-021-03537-1.

Early effects of ventilatory rescue therapies on systemic and cerebral oxygenation in mechanically ventilated COVID-19 patients with acute respiratory distress syndrome: a prospective observational study

Chiara Robba  1   2 , Lorenzo Ball #  3   4 , Denise Battaglini #  4 , Danilo Cardim  5 , Emanuela Moncalvo  3 , Iole Brunetti  4 , Matteo Bassetti  6   7 , Daniele R Giacobbe  6   7 , Antonio Vena  7 , Nicolò Patroniti  3   4 , Patricia R M Rocco  8 , Basil F Matta  9 , Paolo Pelosi  3   4 ; collaborators
Collaborators, Affiliations
Observational Study

Early effects of ventilatory rescue therapies on systemic and cerebral oxygenation in mechanically ventilated COVID-19 patients with acute respiratory distress syndrome: a prospective observational study

Chiara Robba et al. Crit Care. .

Abstract

Background: In COVID-19 patients with acute respiratory distress syndrome (ARDS), the effectiveness of ventilatory rescue strategies remains uncertain, with controversial efficacy on systemic oxygenation and no data available regarding cerebral oxygenation and hemodynamics.

Methods: This is a prospective observational study conducted at San Martino Policlinico Hospital, Genoa, Italy. We included adult COVID-19 patients who underwent at least one of the following rescue therapies: recruitment maneuvers (RMs), prone positioning (PP), inhaled nitric oxide (iNO), and extracorporeal carbon dioxide (CO2) removal (ECCO2R). Arterial blood gas values (oxygen saturation [SpO2], partial pressure of oxygen [PaO2] and of carbon dioxide [PaCO2]) and cerebral oxygenation (rSO2) were analyzed before (T0) and after (T1) the use of any of the aforementioned rescue therapies. The primary aim was to assess the early effects of different ventilatory rescue therapies on systemic and cerebral oxygenation. The secondary aim was to evaluate the correlation between systemic and cerebral oxygenation in COVID-19 patients.

Results: Forty-five rescue therapies were performed in 22 patients. The median [interquartile range] age of the population was 62 [57-69] years, and 18/22 [82%] were male. After RMs, no significant changes were observed in systemic PaO2 and PaCO2 values, but cerebral oxygenation decreased significantly (52 [51-54]% vs. 49 [47-50]%, p < 0.001). After PP, a significant increase was observed in PaO2 (from 62 [56-71] to 82 [76-87] mmHg, p = 0.005) and rSO2 (from 53 [52-54]% to 60 [59-64]%, p = 0.005). The use of iNO increased PaO2 (from 65 [67-73] to 72 [67-73] mmHg, p = 0.015) and rSO2 (from 53 [51-56]% to 57 [55-59]%, p = 0.007). The use of ECCO2R decreased PaO2 (from 75 [75-79] to 64 [60-70] mmHg, p = 0.009), with reduction of rSO2 values (59 [56-65]% vs. 56 [53-62]%, p = 0.002). In the whole population, a significant relationship was found between SpO2 and rSO2 (R = 0.62, p < 0.001) and between PaO2 and rSO2 (R0 0.54, p < 0.001).

Conclusions: Rescue therapies exert specific pathophysiological mechanisms, resulting in different effects on systemic and cerebral oxygenation in critically ill COVID-19 patients with ARDS. Cerebral and systemic oxygenation are correlated. The choice of rescue strategy to be adopted should take into account both lung and brain needs. Registration The study protocol was approved by the ethics review board (Comitato Etico Regione Liguria, protocol n. CER Liguria: 23/2020).

Keywords: Carbon dioxide removal; Cerebral oxygenation; Coronavirus; Prone position; Recruitment maneuvers; Rescue therapies.

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Conflict of interest statement

Dr. Bassetti reports personal fees and other from Angelini, personal fees and other from AstraZeneca, other from Bayer, personal fees and other from Cubist, personal fees and other from Pfizer, personal fees and other from Menarini, personal fees and other from MSD, other from Nabriva, other from Paratek, other from Roche, other from Shionogi, other from Tetraphase, other from The Medicine Company, personal fees and other from Astellas Pharma Inc., personal fees from Gilead Sciences, personal fees from Teva, personal fees from Novartis, grants from Ranbaxy, personal fees from Correvio, personal fees from Molteni, personal fees from Thermo Fisher, outside the submitted work. Dr. Giacobbe reports personal fees from Stepstone Pharma GmbH, personal fees from MSD Italia, personal fees from Correvio Italia, outside the submitted work. Dr. Matta reports personal fees from Masimo.

Figures

Fig. 1
Fig. 1
Scatterplots showing the linear association and correlation (R) between systemic oxygen saturation (SpO2) (left panel) and partial pressure of oxygen (PaO2) (right panel) versus cerebral oxygenation (rSO2) at different study timepoints. Repeated measurements for each patient are plotted in the same color pattern. Linear regression lines are correspondent to repeated measurements within patients
Fig. 2
Fig. 2
Boxplots representing the effect of recruitment maneuvers (RMs) on partial pressure of oxygen (PaO2), cerebral oxygenation (rSO2), and oxygen saturation (SpO2) from baseline, T0 (pre), and after RMs, T1 (post). Values are presented as median and interquartile range
Fig. 3
Fig. 3
Boxplots representing the effect of prone positioning on partial pressure of oxygen (PaO2), cerebral oxygenation (rSO2), and oxygen saturation (SpO2), from baseline, T0 (pre), and after prone positioning, T1 (post). Values are presented as median and interquartile range
Fig. 4
Fig. 4
Boxplots representing the effect of inhaled nitric oxide (iNO) on partial pressure of oxygen (PaO2), cerebral oxygenation (rSO2), and oxygen saturation (SpO2) from baseline, T0 (pre), and after iNO, T1 (post). Values are presented as median and Interquartile range
Fig. 5
Fig. 5
Boxplots representing the effect of ECCO2R or respiratory dialysis on partial pressure of oxygen (PaO2), cerebral oxygenation (rSO2), and oxygen saturation (SpO2) from baseline, T0 (pre), and after CO2 removal, T1 (post). Values are presented as median and interquartile range
See this image and copyright information in PMC

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