Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Randomized Controlled Trial
. 2022 Dec 3;23(1):327.
doi: 10.1186/s12931-022-02258-5.

Non-invasive respiratory support in SARS-CoV-2 related acute respiratory distress syndrome: when is it most appropriate to start treatment?

Riccardo Nevola  1   2 , Antonio Russo  3 , Samuel Scuotto  3 , Simona Imbriani  4 , Concetta Aprea  4 , Marianna Abitabile  4 , Domenico Beccia  4 , Chiara Brin  4 , Caterina Carusone  4 , Francesca Cinone  4 , Giovanna Cirigliano  4 , Sara Colantuoni  4 , Domenico Cozzolino  4 , Giovanna Cuomo  4 , Micol Del Core  4 , Klodian Gjeloshi  4 , Aldo Marrone  4 , Giulia Medicamento  4 , Luciana Agnese Meo  4 , Francesco Nappo  4 , Andrea Padula  4 , Pia Clara Pafundi  5 , Roberta Ranieri  4 , Carmen Ricozzi  4 , Luca Rinaldi  4 , Ciro Pasquale Romano  4 , Rachele Ruocco  4 , Carolina Ruosi  4 , Annabella Salvati  3 , Ferdinando Carlo Sasso  4 , Ausilia Sellitto  4 , Pino Sommese  4 , Angela Villani  4 , Nicola Coppola  3 , Luigi Elio Adinolfi  4
Affiliations
Randomized Controlled Trial

Non-invasive respiratory support in SARS-CoV-2 related acute respiratory distress syndrome: when is it most appropriate to start treatment?

Riccardo Nevola et al. Respir Res. .

Abstract

Background: Acute respiratory distress syndrome (ARDS) is one of the most severe complications of SARS-CoV-2 infection. Non-Invasive Respiratory Support (NRS) as Continuous Positive Airway Pressure (CPAP) and/or Non-Invasive Ventilation (NIV) has been proven as effective in the management of SARS-CoV-2-related ARDS. However, the most appropriate timing for start NRS is unknown.

Methods: We conducted a prospective pilot study including all consecutive patients who developed moderate SARS-CoV-2-related ARDS during hospitalization. Patients were randomly divided into two intervention groups according to ARDS severity (assessed by PaO2/FiO2-P/F) at NRS beginning: group A started CPAP/NIV when P/F was ≤ 200 and group B started CPAP/NIV when P/F was ≤ 150. Eligible patients who did not give their consent to CPAP/NIV until the severe stage of ARDS and started non-invasive treatment when P/F ≤ 100 (group C) was added. The considered outcomes were in-hospital mortality, oro-tracheal intubation (OTI) and days of hospitalization.

Results: Among 146 eligible patients, 29 underwent CPAP/NIV when P/F was ≤ 200 (Group A), 68 when P/F was ≤ 150 (Group B) and 31 patients agreed to non-invasive treatment only when P/F was ≤ 100 (Group C). Starting NRS at P/F level between 151 and 200 did not results in significant differences in the outcomes as compared to treatment starting with P/F ranging 101-150. Conversely, patients undergone CPAP/NIV in a moderate stage (P/F 101-200) had a significantly lower in-hospital mortality rate (13.4 vs. 29.0%, p = 0.044) and hospitalization length (14 vs. 15 days, p = 0.038) than those in the severe stage (P/F ≤ 100). Age and need for continuous ventilation were independent predictors of CPAP/NIV failure.

Conclusions: Starting CPAP/NIV in patients with SARS-CoV-2-related ARDS in moderate stage (100 > P/F ≤ 200) is associated to a reduction of both in-hospital mortality and hospitalization length compared to the severe stage (P/F ≤ 100). Starting CPAP/NIV with a P/F > 150 does not appear to be of clinical utility.

Keywords: ARDS; COVID-19; CPAP; NIV; SARS-CoV-2.

PubMed Disclaimer

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Study design: Group A started CPAP/NIV when P/F fell below 200, Group B underwent CPAP/NIV when P/F fell below 150. Group C derives from patients initially excluded from the study for refusal of non-invasive treatment and who subsequently initiated treatment with CPAP/NIV in a severe stage of ARDS (P/F ≤ 100). CPAP Continuous Positive Airway Pressure, NIV Non-Invasive Ventilation, P/F PaO2/FiO2 rate
Fig. 2
Fig. 2
Flow chart of evaluated SARS-CoV-2 infected patients. CPAP Continuous Positive Airway Pressure, NIV Non-Invasive Ventilation, P/F PaO2/FiO2 rate
Fig. 3
Fig. 3
Above: Kaplan–Meier curves related to the analysis of mortality rates (a) and overall oro-tracheal intubation (OTI, b) among patients undergoing treatment with CPAP/NIV with a P/F between 151 and 200 (group A) and patients who initiated the treatment with a P/F between 101 and 150 (group B). Below: Kaplan–Meier curves related to the analysis of mortality (c) and OTI (d) rates among patients undergone CPAP/NIV in a moderate degree of respiratory distress (group A + B, P/F 101–200) and patients referred for treatment in a severe degree of respiratory distress (group C, P/F ≤ 100)
Fig. 4
Fig. 4
Proposed timing for start CPAP/NIV to maximize results to be evaluated in future powered studies. ARDS Acute Respiratory Distress Syndrome, CPAP Continuous Positive Airway Pressure, NIV Non-Invasive Ventilation, OTI oro-tracheal intubation, P/F PaO2/FiO2 rate; VILI Ventilator Induced Lung Injury
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

References

    1. Grieco DL, Menga LS, Cesarano M, Rosà T, Spadaro S, Bitondo MM, COVID-ICU Gemelli Study Group et al. Effect of helmet noninvasive ventilation vs high-flow nasal oxygen on days free of respiratory support in patients with COVID-19 and moderate to severe hypoxemic respiratory failure: the HENIVOT randomized clinical trial. JAMA. 2021;325:1731–1743. doi: 10.1001/jama.2021.4682. - DOI - PMC - PubMed
    1. Pfeifer M, Ewig S, Voshaar T, Randerath WJ, Bauer T, Geiseler J, et al. Position paper for the state-of-the-art application of respiratory support in patients with COVID-19. Respiration. 2020;99:521–542. doi: 10.1159/000509104. - DOI - PMC - PubMed
    1. Bertaina M, Nuñez-Gil IJ, Franchin L, Fernández Rozas I, Arroyo-Espliguero R, Viana-Llamas MC, HOPE COVID-19 investigators et al. Non-invasive ventilation for SARS-CoV-2 acute respiratory failure: a subanalysis from the HOPE COVID-19 registry. Emerg Med J. 2021;38:359–365. doi: 10.1136/emermed-2020-210411. - DOI - PubMed
    1. Nightingale R, Lewis J, Monsell KR, Jones L, Smith C, Kundu S, et al. CPAP delivered outside critical care during the second wave of COVID-19: outcomes from a UK respiratory surge unit. BMJ Open Respir Res. 2021;8:e000907. doi: 10.1136/bmjresp-2021-000907. - DOI - PMC - PubMed
    1. Brusasco C, Corradi F, Di Domenico A, Raggi F, Timossi G, Santori G, Galliera CPAP-Covid-19 study group et al. Continuous positive airway pressure in COVID-19 patients with moderate-to-severe respiratory failure. Eur Respir J. 2021;57:2002524. doi: 10.1183/13993003.02524-2020. - DOI - PMC - PubMed

Publication types