Noninvasive Respiratory Assist Devices in the Management of COVID-19-related Hypoxic Respiratory Failure: Pune ISCCM COVID-19 ARDS Study Consortium (PICASo)

Abstract

A bstract Objective To determine whether high-flow nasal oxygen (HFNO) or noninvasive ventilator (NIV) can avoid invasive mechanical ventilation (IMV) in COVID-19-related acute respiratory distress syndrome (ADRS), and the outcome predictors of these modalities. Design Multicenter retrospective study conducted in 12 ICUs in Pune, India. Patients Patients with COVID-19 pneumonia who had PaO 2 /FiO 2 ratio <150 and were treated with HFNO and/or NIV. Intervention HFNO and/or NIV. Measurements The primary outcome was to assess the need of IMV. Secondary outcomes were death at Day 28 and mortality rates in different treatment groups. Main results Among 1,201 patients who met the inclusion criteria, 35.9% (431/1,201) were treated successfully with HFNO and/or NIV and did not require IMV. About 59.5% (714/1,201) patients needed IMV for the failure of HFNO and/or NIV. About 48.3, 61.6, and 63.6% of patients who were treated with HFNO, NIV, or both, respectively, needed IMV. The need of IMV was significantly lower in the HFNO group ( p <0.001). The 28-day mortality was 44.9, 59.9, and 59.6% in the patients treated with HFNO, NIV, or both, respectively ( p <0.001). On multivariate regression analysis, presence of any comorbidity, SpO 2 <90%, and presence of nonrespiratory organ dysfunction were independent and significant determinants of mortality ( p <0.05). Conclusions During COVID-19 pandemic surge, HFNO and/or NIV could successfully avoid IMV in 35.5% individuals with PO 2 /FiO 2 ratio <150. Those who needed IMV due to failure of HFNO or NIV had high (87.5%) mortality. How to cite this article Jog S, Zirpe K, Dixit S, Godavarthy P, Shahane M, Kadapatti K, et al. Noninvasive Respiratory Assist Devices in the Management of COVID-19-related Hypoxic Respiratory Failure: Pune ISCCM COVID-19 ARDS Study Consortium (PICASo). Indian J Crit Care Med 2022;26(7):791–797.

Efficacy and Safety of High PEEP NIV in COVID-19 Patients

“…This is comparable to the study by Jog et al, which investigated the treatment of COVID-19 patients with severe ARDS (P/F < 150) with HFNO and/or NIV due to unavailability of IMV and reported that 35.9% of such patients managed to avoid intubation. 25 Mortality in patients who required a switch to IMV was 87.5%.…”

“…This is comparable to the study by Jog et al, which investigated the treatment of COVID-19 patients with severe ARDS (P/F < 150) with HFNO and/or NIV due to unavailability of IMV and reported that 35.9% of such patients managed to avoid intubation. 25 Mortality in patients who required a switch to IMV was 87.5%. The most prominent factors leading to NIV failure in this study were increased work of breathing and ventilator asynchrony, impaired consciousness, and hemodynamic disorder.…”

An observational study on the timing of intubation and outcome in COVID-19 ARDS patients who were treated with high flow nasal oxygen prior to invasive mechanical ventilation: A time series analysis (InOutHFNO trial)

“…But previous studies have shown that those patients who fail lengthy HFNO application and ultimately land up in IMV have high mortality. [ 4 , 5 ] Prolong HFNO trial increases the duration of spontaneous respiration in AHRF patients, which amplifies the lung damage by perpetuating the process called patient’s self-inflicting lung injury (P-SILI), where increased negative intrapleural pressure due to increased work of breathing creates an unduly high transpulmonary pressure resulting in increased stress and strain in an already injured COVID lung. [ 14 ] In conjunction with increased respiratory rate, this phenomenon further damages the COVID-19 lung by a process called ‘Ergo trauma’, typically described in patients with IMV.…”

“…In this study, overall ICU and in-hospital mortality is 67.2%, comparable to a recent study from western India, which reported an ICU mortality of 68.7% in a cohort of 147 severe COVID-19 patients requiring invasive mechanical ventilation. [ 5 ] The strength of our study is the time period analysis of HFNO failure and outcome without considering an arbitrary cut-off period to define early and late intubation, a reasonable sample size during the early days of HFNO failure and an exclusive intensive care population. Being a single-centre study, the homogeneity of caregivers during the study period ensures a uniform protocol for intubating an HFNC failure patient.…”

“…[ 4 ] Similar data have emerged from CAHRF patients treated with prolonged HFNO and NIV. [ 5 ] Thus, the timing of intubation in this patient population has become a subject of active research. Studies looking at the timing of intubation in patients on non-invasive respiratory support (NIRS) and outcome have defined ‘early’ and ‘delayed’ intubation with a variable cut-off period which was selected arbitrarily or based on previous studies in this field.…”