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. 2021 May 25;25(1):175.
doi: 10.1186/s13054-021-03580-y.

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  1   2 , Hernán Aguirre-Bermeo  3 , Philipp K Buehler  1 , Mario Alfaro-Farias  4 , Bernd Yuen  5 , Sascha David  6 , Thomas Tschoellitsch  7 , Tobias Wengenmayer  8 , Anita Korsos  9 , Alberto Fogagnolo  10 , Gian-Reto Kleger  11 , Maddalena A Wu  12 , Riccardo Colombo  13 , Fabrizio Turrini  14 , Antonella Potalivo  15 , Emanuele Rezoagli  16 , Raquel Rodríguez-García  17 , Pedro Castro  18 , Arantxa Lander-Azcona  19 , Maria C Martín-Delgado  20 , Herminia Lozano-Gómez  21 , Rolf Ensner  22 , Marc P Michot  23 , Nadine Gehring  24 , Peter Schott  25 , Martin Siegemund  26 , Lukas Merki  27 , Jan Wiegand  28 , Marie M Jeitziner  29 , Marcus Laube  30 , Petra Salomon  31 , Frank Hillgaertner  32 , Alexander Dullenkopf  33 , Hatem Ksouri  34 , Sara Cereghetti  35 , Serge Grazioli  36 , Christian Bürkle  37 , Julien Marrel  38 , Isabelle Fleisch  39 , Marie-Helene Perez  40 , Anja Baltussen Weber  41 , Samuele Ceruti  42 , Katharina Marquardt  43 , Tobias Hübner  44 , Hermann Redecker  45 , Michael Studhalter  46 , Michael Stephan  47 , Daniela Selz  48 , Urs Pietsch  49 , Anette Ristic  50 , Antje Heise  51 , Friederike Meyer Zu Bentrup  52 , Marilene Franchitti Laurent  53 , Patricia Fodor  54 , Tomislav Gaspert  55 , Christoph Haberthuer  56 , Elif Colak  57 , Dorothea M Heuberger  1 , Thierry Fumeaux  2   58 , Jonathan Montomoli  2   59 , Philippe Guerci  2   60 , Reto A Schuepbach  1   2 , Matthias P Hilty  1   2 , Ferran Roche-Campo  61 ; RISC-19-ICU Investigators
Collaborators, Affiliations

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 et al. Crit Care. .

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.

Keywords: ARDS; COVID-19; High flow oxygen therapy; Invasive mechanical ventilation; Noninvasive mechanical ventilation; Patient self-inflicted lung injury; Respiratory support; Standard oxygen therapy.

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Conflict of interest statement

The authors declare that they have no competing interests regarding the present study.

Figures

Fig. 1
Fig. 1
Study flowchart
Fig. 2
Fig. 2
Kaplan–Meier curves for the a incidence of intubation and b intensive care unit mortality stratified by respiratory support strategy at intensive care unit admission. Forest plots reporting crude and multivariable adjusted (*italic) hazard ratios with 95% confidence intervals are displayed below the Kaplan–Meier curves for each respiratory support strategy. †p values for between groups survival curve difference were calculated by means of the log-rank test
Fig. 3
Fig. 3
Kaplan–Meier curves for a intensive care unit mortality and b intensive care unit length of stay stratified by respiratory support strategy at intensive care unit admission (only intubated patients). Forest plots reporting crude and multivariable adjusted (*italic) hazard ratios with 95% confidence intervals are displayed below the Kaplan–Meier curves for each respiratory support strategy. †p values for between groups survival curve difference were calculated by means of the log-rank test
See this image and copyright information in PMC

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