Neurologic Outcomes of Survivors of COVID-19-Associated Acute Respiratory Distress Syndrome Requiring Intubation

Abstract

Objectives: To describe 3-6-month neurologic outcomes of survivors of COVID-19-associated acute respiratory distress syndrome, invasively ventilated in the ICU.

Design: A bicentric prospective study during the two first waves of the pandemic (March to May and September to December, 2020).

Setting: Two academic hospital ICUs, Paris, France.

Patients: Adult COVID-19-associated acute respiratory distress syndrome survivors, invasively ventilated in the ICU, were eligible for a neurologic consultation between 3 and 6 months post ICU discharge.

Interventions: Follow-up by face-to-face neurologic consultation.

Measures and main results: The primary endpoint was favorable functional outcome defined by a modified Rankin scale score less than 2, indicating survival with no significant disability. Secondary endpoints included mild cognitive impairment (Montreal Cognitive Assessment score < 26), ICU-acquired weakness (Medical Research Council score < 48), anxiety and depression (Hospital Anxiety and Depression score > 7), and posttraumatic stress disorder (posttraumatic stress disorder checklist for Diagnostic and Statistical Manual of Mental Disorders 5 score > 30). Of 54 eligible survivors, four non-French-speaking patients were excluded, eight patients were lost-to-follow-up, and one died during follow-up. Forty-one patients were included. Time between ICU discharge and neurologic consultation was 3.8 months (3.6-5.9 mo). A favorable functional outcome was observed in 16 patients (39%) and mild cognitive impairment in 17 of 33 patients tested (52%). ICU-acquired weakness, depression or anxiety, and posttraumatic stress disorder were reported in six of 37 cases (16%), eight of 31 cases (26%), and two of 27 cases (7%), respectively. Twenty-nine patients (74%) required rehabilitation (motor, cognitive, or psychologic). ICU and hospital lengths of stay, tracheostomy, and corticosteroids were negatively associated with favorable outcome. By contrast, use of alpha-2 agonists during ICU stay was associated with favorable outcome.

Conclusions: COVID-19-associated acute respiratory distress syndrome requiring intubation led to slight-to-severe functional disability in about 60% of survivors 4 months after ICU discharge. Cognitive impairment, muscle weakness, and psychologic symptoms were frequent. A large multicenter study is warranted to allow identification of modifiable factors for improving long-term outcome.

Figure 1.

Functional outcome defined by the modified Rankin Scale (mRS) score at 4 mo after ICU discharge. Data from 41 survivors of COVID-19–associated acute respiratory distress syndrome requiring invasive mechanical ventilation. Distribution of patients depending on their outcome on the mRS scale. 0–1 = asymptomatic or symptomatic without disability. 2–4 = slight to severe disability.

Figure 2.

Distribution of cognitive deficits using the Montreal cognitive assessment. Data from 33 survivors of COVID-19–associated acute respiratory distress syndrome requiring invasive mechanical ventilation in an ICU. Delayed recall was the most affected domain.