Noninvasive respiratory support outside the intensive care unit for acute respiratory failure related to coronavirus-19 disease: a systematic review and meta-analysis

Abstract

Background Noninvasive respiratory support (NIRS) has been diffusely employed outside the intensive care unit (ICU) to face the high request of ventilatory support due to the massive influx of patients with acute respiratory failure (ARF) caused by coronavirus-19 disease (COVID-19). We sought to summarize the evidence on clinically relevant outcomes in COVID-19 patients supported by NIV outside the ICU. Methods We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials register, along with medRxiv and bioRxiv repositories for pre-prints, for observational studies and randomized controlled trials, from inception to the end of February 2021. Two authors independently selected the investigations according to the following criteria: (1) observational study or randomized clinical trials enrolling ≥ 50 hospitalized patients undergoing NIRS outside the ICU, (2) laboratory-confirmed COVID-19, and (3) at least the intra-hospital mortality reported. Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines were followed. Data extraction was independently performed by two authors to assess: investigation features, demographics and clinical characteristics, treatments employed, NIRS regulations, and clinical outcomes. Methodological index for nonrandomized studies tool was applied to determine the quality of the enrolled studies. The primary outcome was to assess the overall intra-hospital mortality of patients under NIRS outside the ICU. The secondary outcomes included the proportions intra-hospital mortalities of patients who underwent invasive mechanical ventilation following NIRS failure and of those with ‘do-not-intubate’ (DNI) orders. Results Seventeen investigations (14 peer-reviewed and 3 pre-prints) were included with a low risk of bias and a high heterogeneity, for a total of 3377 patients. The overall intra-hospital mortality of patients receiving NIRS outside the ICU was 36% [30–41%]. 26% [21–30%] of the patients failed NIRS and required intubation, with an intra-hospital mortality rising to 45% [36–54%]. 23% [15–32%] of the patients received DNI orders with an intra-hospital mortality of 72% [65–78%]. Oxygenation on admission was the main source of between-study heterogeneity. Conclusions During COVID-19 outbreak, delivering NIRS outside the ICU revealed as a feasible strategy to cope with the massive demand of ventilatory assistance. Registration PROSPERO, https://www.crd.york.ac.uk/prospero/, CRD42020224788, December 11, 2020.

Impact of time to intubation on mortality and pulmonary sequelae in critically ill patients with COVID-19: a prospective cohort study

“…However, the authors considered the baseline time of the study as ICU admission, and thus respiratory support management conducted in the general ward before ICU admission was not considered. Because the use of NIMV or HFNC outside the ICU has been widely accepted during the COVID-19 pandemic [ 13 ], we proposed a different approach (the first 48 h from the first respiratory support), which might be more appropriate and fits with real clinical practice.…”

“…As the pandemic progressed, hospitals were overloaded and the number of ventilators was limited; thus, the trend to use noninvasive techniques such as NIMV or high-flow oxygen therapy by nasal cannula (HFNC) increased. Moreover, the strategy for using these techniques outside the ICU is even more widely accepted [ 13 ]. To date, the effectiveness and optimal respiratory support strategy for CARDS are still unknown.…”

Non-invasive Respiratory Support in COVID-19: A Narrative Review

“…Regarding the efficacy to avoid intubation, in the previously mentioned meta-analysis, from the 75% of survivors in the group of patients who were candidates for intubation, 31% required IMV and 43% only SRNI (22). In a study including patients who were candidates for intubation and invasive ventilation but who could not receive such treatment due to the shortage in the context of massive influx of patients, intubation was avoided in 37% of patients, who were managed only with CPAP (59).…”

“…Overall mortality was 38%, although it is possible to distinguish the group of patients without therapeutic limitation (19%) from that of patients with orders of no intubation (72%). Mortality in patients with NIV failure who were ultimately intubated was 45% ( 22 ).…”

Research on SARS-COV-2 pandemic: a narrative review focused on the Italian contribution

“…Therefore, an early trial with helmet NIV could be reasonable, though the evidence is weak. NIV application is also feasible outside the ICU to cope with the massive demand of ventilatory assistance [ 8 ]. However, close monitoring of respiratory function remains fundamental to not delay intubation, whenever needed [ 6 ].…”