Airway pressure release ventilation in mechanically ventilated patients with COVID-19: a multicenter observational study

Abstract

Background: Evidence prior to the coronavirus disease 2019 (COVID-19) pandemic suggested that, compared with conventional ventilation strategies, airway pressure release ventilation (APRV) can improve oxygenation and reduce mortality in patients with acute respiratory distress syndrome. We aimed to assess the association between APRV use and clinical outcomes among adult patients receiving mechanical ventilation for COVID-19 and hypothesized that APRV use would be associated with improved survival compared with conventional ventilation.

Methods: A total of 25 patients with COVID-19 pneumonitis was admitted to intensive care units (ICUs) for invasive ventilation in Perth, Western Australia, between February and May 2020. Eleven of these patients received APRV. The primary outcome was survival to day 90. Secondary outcomes were ventilation-free survival days to day 90, mechanical complications from ventilation, and number of days ventilated.

Results: Patients who received APRV had a lower probability of survival than did those on other forms of ventilation (hazard ratio, 0.17; 95% confidence interval, 0.03-0.89; P=0.036). This finding was independent of indices of severity of illness to predict the use of APRV. Patients who received APRV also had fewer ventilator-free survival days up to 90 days after initiation of ventilation compared to patients who did not receive APRV, and survivors who received APRV had fewer ventilator-free days than survivors who received other forms of ventilation. There were no differences in mechanical complications according to mode of ventilation.

Conclusions: Based on the findings of this study, we urge caution with the use of APRV in COVID-19.

Keywords: COVID-19; intensive care; respiration, artificial; ventilation mode, APRV.

Figure 1.

Flowchart of patients included in the study. ICU: intensive care unit.

Figure 2.

Survival curves for patients treated and untreated with airway pressure release ventilation (APRV) during their intensive care unit stay (n=25). The APRV group had a lower probability of survival to day 90 compared to the non-APRV group of mechanically ventilated patients (hazard ratio of survival, 0.17; 95% confidence interval, 0.03–0.89; P=0.036).

Figure 3.

The difference in ventilating driving pressure (peak inspiratory minus end-expiratory airway pressure) from initiation of invasive mechanical ventilation until day 10 between those treated and untreated by airway pressure release ventilation (APRV).

Figure 4.

The difference in respiratory compliance from initiation of invasive mechanical ventilation until day 10 between those treated and untreated by airway pressure release ventilation (APRV).