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

Abstract

Background: There is high prevalence of severe hypoxia, use of invasive mechanical ventilation, and high mortality in patients with severe coronavirus disease 2019 (COVID-19) pneumonitis. Evidence prior to the 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.

Respiratory system mechanics, gas exchange, and outcomes in mechanically ventilated patients with COVID-19-related acute respiratory distress syndrome: a systematic review and meta-analysis

“…The pooled reported C RS in patients from studies of unselected COVID-19-related ARDS was 35·8 mL/cm H 2 O (95% CI 33·9–37·8; I 2 =96·9%, τ 2 =32·6; high certainty; figure 2 ). 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 In these studies, C RS dispersion was not significantly different from a normal distribution (Shapiro-Wilk test p=0·92; figure 3 ). The pooled reported C RS in all patients from studies of selected and unselected COVID-19-related ARDS was 34·7 mL/cm H 2 O (32·8–36·6; 97·2%, 43·6; high certainty; appendix p 5 ).…”

Comparison of characteristics and ventilatory course between coronavirus disease 2019 and Middle East respiratory syndrome patients with acute respiratory distress syndrome

“…Our results do not advocate against the use of high-flow oxygen or for early intubation, but open doors for further research and emphasize caution when dealing with these patients with ARDS. In both study groups, we did not employ airway release pressure ventilation, and recent research has advocated against its use in COVID-19 patients with ARDS [ 25 ].…”

Does airway pressure release ventilation offer new hope for treating acute respiratory distress syndrome?

“… [37] , [38] , [39] Recently, Mahmoud et al [40] found that APRV may improve oxygenation, alveolar ventilation, and CO 2 clearance in patients with COVID-19 and refractory hypoxemia. Moreover, Zorbas et al [41] urged caution with the use of APRV in patients with COVID-19.…”