Is continuous positive airway pressure (CPAP) a new standard of care for type 1 respiratory failure in COVID-19 patients? A retrospective observational study of a dedicated COVID-19 CPAP service

Nightingale, Rebecca; Nwosu, Nneka; Kutubudin, Farheen; Fletcher, Tom; Lewis, J. M.; Frost, Frederick; Haigh, Kathryn; Robinson, Ryan; Kumar, Ayesha; Jones, Gareth; Brown, Deborah; Abouyannis, Michael; Beadsworth, Mike; Hampshire, Peter; Aston, Stephen; Gautam, Manish; Burhan, Hassan

doi:10.1136/bmjresp-2020-000639

Cited by 73 publications

(68 citation statements)

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“…intubation rate of 38%, which was similar to our results [27]. A French two period retrospective study favours CPAP over oxygen: intubation-free survival was 77% (29/38) with CPAP compared to 43% (6/14) with oxygen (p = 0,043).…”

Section: Plos Onesupporting

confidence: 90%

Continuous Positive Airway Pressure (CPAP) face-mask ventilation is an easy and cheap option to manage a massive influx of patients presenting acute respiratory failure during the SARS-CoV-2 outbreak: A retrospective cohort study

et al. 2020

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Section: Plos Onesupporting

confidence: 90%

Continuous Positive Airway Pressure (CPAP) face-mask ventilation is an easy and cheap option to manage a massive influx of patients presenting acute respiratory failure during the SARS-CoV-2 outbreak: A retrospective cohort study

et al. 2020

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“…Encouragingly, within the UK (April 2020) a positive case series review of 24 patients who received CPAP treatment, demonstrated that 58% of patients avoided mechanical ventilation and that there was a remarkable 79% survival rate. 18 Additionally, beneficial CPAP impact on prognosis has been demonstrated where non-responders had a double increase in mortality when compared with responders. 19 On reflection and as evidence emerges, our experiences in developing care pathways in the treatment of COVID-19 have potentially been mirrored throughout the UK and internationally.…”

Section: Discussionmentioning

confidence: 99%

CPAP management of COVID-19 respiratory failure: a first quantitative analysis from an inpatient service evaluation

et al. 2020

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ObjectiveTo evaluate the role of continuous positive air pressure (CPAP) in the management of respiratory failure associated with COVID-19 infection. Early clinical management with limited use of CPAP (3% of patients) was compared with a later clinical management strategy which had a higher proportion of CPAP use (15%).DesignRetrospective case-controlled service evaluation for a single UK National Health Service (NHS) Trust during March–June 2020 designed and conducted solely to estimate the effects of current care.SettingThe acute inpatient unit in Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, a medium-sized English NHS Trust.Participants206 patients with antigen confirmed COVID-19 disease and severe acute respiratory syndrome admitted between 17 March 2020 and 3 April 2020 for the early group (controls), and between 10 April 2020 and 11 May 2020 for the late group (cases). Follow-up for all cases was until 11 June by which time all patients had a final outcome of death or discharge. Both groups were composed of 103 patients. Cases and controls were matched by age and sex.Outcome measureThe outcome measure was the proportion of patients surviving at time t (time from the positive result of COVID-19 test to discharge/death date). The predictors were CPAP intervention, intubation, residence in care homes and comorbidities (renal, pulmonary, cardiac, hypertension and diabetes). A stratified Cox proportional hazard for clustered data (via generalised estimating equations) and model selection algorithms were employed to identify the effect of CPAP on patients’ survival and the effect on gas exchange as measured by alveolar arterial (A-a) gradient and timing of CPAP treatment on CPAP patients’ survival.ResultsCPAP was found to be significantly (HR 0.38, 95% CI 0.36 to 0.40) associated with lower risk of death in patients with hospital stay equal to, or below 7 days. However, for longer hospitalisation CPAP was found to be associated with increased risk of death (HR 1.72, 95% CI 1.40 to 2.12). When CPAP was initiated within 4 days of hospital admission, the survival probability was above 73% (95% CI 53% to 99%). In addition, lower A-a gradient was associated with lower risk of death in CPAP patients (HR 1.011, 95% CI 1.010 to 1.013). The selected model (best fit) was stratified by sex and clustered by case/control groups. The predictors were age, intubation, hypertension and the residency from care homes, which were found to be statistically significantly associated with patient’s death/discharge.ConclusionsCPAP is a simple and cost-effective intervention. It has been established for care of other respiratory disorders but not for COVID-19 respiratory failure. This evaluation establishes that CPAP as a potentially viable treatment option for this group of patients during the first days of hospital admission. As yet there is limited availability of quantitative research on CPAP use for COVID-19. Whist this work is hampered by both the relatively small sample size and retrospective design (which reduced the ability to control potential confounders), it represents evidence of the significant benefit of early CPAP intervention. This evaluation should stimulate further research questions and larger study designs on the potential benefit of CPAP for COVID-19 infections. Globally, this potentially beneficial low cost and low intensity therapy could have added significance economically for healthcare provision in less developed countries.

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“…This rate is concordant to other case series even if still few data on NIPPV failure in these patients are available. 18 Patients who were intubated had a signi cant lower P/F ratio compared to those treated only with NIPPV.…”

Section: Discussionmentioning

confidence: 90%

“…38 patients (73%) were judged eligible for ETI. 18 (34.6%) were intubated. 16 (30.8%) patients died: 7 (38.9%) and 9 (26.5%) in the ETI and non-ETI group respectively.…”

Section: Resultsmentioning

confidence: 99%

CPAP Use in Covid-19 Patients: A Retrospective Observational Study in the Emergency Department.

Capsoni

Privitera

Mazzone

et al. 2020

Preprint

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BackgroundDuring COVID-19 outbreak, with the increasing number of patients presenting with acute respiratory failure (ARF), a large use of non-invasive positive pressure ventilation (NIPPV) was done in the Emergency Departments (EDs) and medical wards despite the lack of recommendations. We aimed to assess the use of continuous positive airway pressure (CPAP) in the ED. The primary endpoint was the rate of CPAP failure and the need of endotracheal intubation (ETI). Secondary endpoints were in-hospital mortality and intensive care unit (ICU) and in-hospital length of stay. Study design and MethodsA retrospective observational study enrolling adult patients admitted to the ED of Niguarda Hospital, Milan, Italy, with ARF due to COVID-19 pneumonia from March 18th to April 18th 2020, was conducted. Only patients who strictly followed a local CPAP protocol were enrolled. ResultsA total of 52 patients were included in this study. 38 patients (73%) were judged eligible for ETI. 18 (34.6%) were intubated. 16 (30.8%) patients died: 7 (38.9%) and 9 (26.5%) in the ETI and non-ETI group respectively. The median hospital length of stay was different in ETI and non-ETI patients: 26 days [IQR 16-37] vs 15 days [IQR 9-17] (p=0.005). The median invasive mechanical ventilation time was 11 days [IQR 7-21] with an ICU length of stay of 14.5 days [IQR 10-28]. During the CPAP trial, variations between ETI and non-ETI patients over time were found for positive end-expiratory pressure (PEEP) (p=0.003) and respiratory rate (RR) (p=0.059).ConclusionsA short closed monitored CPAP trial could be considered for ARF due to COVID-19 pneumonia before considering ETI. A progressive PEEP titration should target patient’s SpO2 improvement and RR reduction. More studies are needed to evaluate the efficacy and predictors of failure of CPAP and NIPPV in patients with ARF due to COVID-19 pneumonia.

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Is continuous positive airway pressure (CPAP) a new standard of care for type 1 respiratory failure in COVID-19 patients? A retrospective observational study of a dedicated COVID-19 CPAP service

Cited by 73 publications

References 2 publications

Continuous Positive Airway Pressure (CPAP) face-mask ventilation is an easy and cheap option to manage a massive influx of patients presenting acute respiratory failure during the SARS-CoV-2 outbreak: A retrospective cohort study

Continuous Positive Airway Pressure (CPAP) face-mask ventilation is an easy and cheap option to manage a massive influx of patients presenting acute respiratory failure during the SARS-CoV-2 outbreak: A retrospective cohort study

CPAP management of COVID-19 respiratory failure: a first quantitative analysis from an inpatient service evaluation

CPAP Use in Covid-19 Patients: A Retrospective Observational Study in the Emergency Department.

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