Natural history, trajectory, and management of mechanically ventilated COVID-19 patients in the United Kingdom

Abstract

Purpose The trajectory of mechanically ventilated patients with coronavirus disease 2019 (COVID-19) is essential for clinical decisions, yet the focus so far has been on admission characteristics without consideration of the dynamic course of the disease in the context of applied therapeutic interventions. Methods We included adult patients undergoing invasive mechanical ventilation (IMV) within 48 h of intensive care unit (ICU) admission with complete clinical data until ICU death or discharge. We examined the importance of factors associated with disease progression over the first week, implementation and responsiveness to interventions used in acute respiratory distress syndrome (ARDS), and ICU outcome. We used machine learning (ML) and Explainable Artificial Intelligence (XAI) methods to characterise the evolution of clinical parameters and our ICU data visualisation tool is available as a web-based widget ( https://www.CovidUK.ICU ). Results Data for 633 adults with COVID-19 who underwent IMV between 01 March 2020 and 31 August 2020 were analysed. Overall mortality was 43.3% and highest with non-resolution of hypoxaemia [60.4% vs17.6%; P < 0.001; median PaO 2 /FiO 2 on the day of death was 12.3(8.9–18.4) kPa] and non-response to proning (69.5% vs.31.1%; P < 0.001). Two ML models using weeklong data demonstrated an increased predictive accuracy for mortality compared to admission data (74.5% and 76.3% vs 60%, respectively). XAI models highlighted the increasing importance, over the first week, of PaO 2 /FiO 2 in predicting mortality. Prone positioning improved oxygenation only in 45% of patients. A higher peak pressure (OR 1.42[1.06–1.91]; P < 0.05), raised respiratory component (OR 1.71[ 1.17–2.5]; P < 0.01) and cardiovascular component (OR 1.36 [1.04–1.75]; P < 0.05) of the sequential organ failure assessment (SOFA) score and raised lactate (OR 1.33 [0.99–1.79]; P = 0.057) immediately prior to application of prone positioning were associated with lack of oxygenation response. Prone positioning was not applied to 76% of patients with moderate hypoxemia and 45% of those with severe hypoxemia and patients who died without receiving proning interventions had more missed opportunities for prone intervention [7 (3–15.5) versus 2 (0–6); P < 0.001]. Despite the severity of gas exchange deficit, most patients received lung-protective ventilation with tidal volumes less than 8 mL/kg and plateau pressures less than 30cmH 2 O. This was despite systematic errors in measurement of height and derived ideal body weight. Conclusions Refractory hypoxaemia remains a major associ...

Rapidly improving acute respiratory distress syndrome in COVID-19: a multi-centre observational study

“…The prevalence of persistent severe ARDS seems similar to non-COVID ARDS [ 11 ] (or even non-COVID acute hypoxemic respiratory failure) [ 25 ] and so is the mortality. This is also in line with findings of a recent observational study from the United Kingdom, which reported that refractory hypoxemia remains a major determinant of mortality in the COVID-19 era [ 15 ].…”

“…While trajectory-related subphenotypes (namely, rapidly improving ARDS and persistent severe ARDS) have been characterized in the pre-COVID era [ 4 , 5 , 11 ], little is known about the trajectory of ARDS in patients with COVID-19. Given that the trajectory of COVID-related ARDS is increasingly recognized as more clinically relevant than a single daily value of oxygenation [ 14 , 15 ], we endeavoured to determine the prevalence and prognosis of rapidly improving ARDS and of persistent severe ARDS among intubated patients with COVID-19.…”

Effect of Vitamin C on Clinical Outcomes of Critically Ill Patients With COVID-19: An Observational Study and Subsequent Meta-Analysis

“…However, there was no difference between the compared groups (vitamin C vs. control) in terms of known predictors of mortality in COVID-19 (and therefore potential confounders), such as age, sex, comorbidities, SOFA score and lung mechanics at baseline (35). If anything, baseline oxygenation of mechanically ventilated patients was worse in the vitamin C than control group (PaO 2 :FiO 2 95.4 vs. 142.5), which could attenuate a potentially beneficial effect of vitamin C on mortality.…”

Education to save lives: C19SPACE, the COVID19 Skills PrepAration CoursE

“…Health systems across Europe were overwhelmed by the first coronavirus disease 2019 (COVID-19) wave [ 1 – 3 ]. While initially media and governments focused on shortages of ventilators, devices, and drugs [ 4 , 5 ], the European Society of Intensive Care Medicine (ESICM) leadership immediately focused the attention on intensive care unit (ICU) teams and competencies of healthcare workers in case of ICU surges [ 6 , 7 ].…”