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. 2021 Oct:65:237-245.
doi: 10.1016/j.jcrc.2021.06.016. Epub 2021 Jul 7.

Mortality associated with early changes in ARDS severity in COVID-19 patients - Insights from the PRoVENT-COVID study

Michiel T U Schuijt  1 , Ignacio Martin-Loeches  2 , Marcus J Schultz  3 , Frederique Paulus  4 , Ary Serpa Neto  5 ; PRoVENT-COVID; PRoVENT-COVID Collaborative Group members. Electronic address: provent-covid@amsterdamumc.nl; PRoVENT-COVID Collaborative Group members
Collaborators, Affiliations

Mortality associated with early changes in ARDS severity in COVID-19 patients - Insights from the PRoVENT-COVID study

Michiel T U Schuijt et al. J Crit Care. 2021 Oct.

Abstract

Purpose: We investigated changes in ARDS severity and associations with outcome in COVID-19 ARDS patients.

Methods: We compared outcomes in patients with ARDS classified as 'mild', 'moderate' or 'severe' at calendar day 1, and after reclassification at calendar day 2. The primary endpoint was 28-day mortality. We also identified which ventilatory parameters had an association with presence of severe ARDS at day 2. We repeated the analysis for reclassification at calendar day 4.

Results: Of 895 patients, 8.5%, 60.1% and 31.4% had mild, moderate and severe ARDS at day 1. These proportions were 13.5%, 72.6% and 13.9% at day 2. 28-day mortality was 25.3%, 31.3% and 32.0% in patients with mild, moderate and severe ARDS at day 1 (p = 0.537), compared to 28.6%, 29.2% and 44.3% in patients reclassified at day 2 (p = 0.005). No ventilatory parameter had an independent association with presence of severe ARDS at day 2. Findings were not different reclassifying at day 4.

Conclusions: In this cohort of COVID-19 patients, ARDS severity and mortality between severity classes changed substantially over the first 4 days of ventilation. These findings are important, as reclassification could help identify target patients that may benefit from alternative approaches.

Keywords: ARDS; Acute respiratory distress syndrome; COVID–19; Coronavirus disease 2019; Mortality.

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Conflict of interest statement

Declaration of Competing Interest ASN reports personal fees from Dräger, outside of the submitted work. The other authors declare no competing interests.

Figures

Unlabelled Image
Graphical abstract
Fig. 1
Fig. 1
Evolution of ARDS severity over the first 2 calendar days of invasive ventilation. Chord diagram depicting the evolution of ARDS severity at day 1 and subsequent ARDS severity at day 2. The bottom part of the diagram represents patients ranked by ARDS severity at day 1, the top part represents the same patients ranked according to presence and evolution of ARDS severity at day 2. Ribbons show the evolution of ARDS from day 1 to day 2. The first diagram (a) presents all patients combined. The other diagrams (b–d) highlight ARDS severity classes separately. Of 76 patients with mild ARDS at day 1, 3 (3.9%), 27 (35.5%), 45 (59.2%) and 1 (1.3%) patients had respectively no, mild, moderate and severe ARDS at day 2. Of 538 patients with moderate ARDS at day 1, 5 (0.9%), 77 (14.3%), 408 (75.8%) and 48 (8.9%) patients had respectively no, mild, moderate and severe ARDS at day 2. Of 281 patients with severe ARDS at day 1, 16 (5.7%), 191 (68.0%) and 74 (26.3%) patients had respectively mild, moderate and severe ARDS at day 2.
Fig. 2
Fig. 2
Kaplan–Meier curves for 28–day mortality for ARDS severity at calendar day 1 and 2. The left diagram (a) shows the probability of 28–day mortality by ARDS severity class at calendar day 1. The right diagram (b) shows the probability of 28–day mortality by ARDS severity class at calendar day 2. Kaplan–Meier curves comparing the probability of survival in mild (blue), moderate (orange), and severe ARDS (red) groups. Log-rank tests show an overall difference between groups and a lower probability of 28–day mortality survival in the severe ARDS group as compared to the mild and moderate ARDS group at calendar day 2. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
See this image and copyright information in PMC

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