Noninvasive ventilation for COVID-19-associated acute hypoxaemic respiratory failure: experience from a single centre

Sivaloganathan, A; Nasim-Mohi, Myra; Brown, Madison; Abdul, Nabil; Jackson, Alexander; Fletcher, Sophie; Grocott, Michael P.W.; Dushianthan, Ahilanandan; Gupta, Sanjay; Nixon, Julian; Levett, Denny; Stewart, Michael; Sparkes, David; Chambers, Robert; Nolan, Kathleen; Tanser, S J; Fennell, Jon; Celinski, Michael; Richardson, D. L.; Cusack, Rebecca; Skinner, Benjamin; Nicholson-Robert, Timothy; Wakatsuki, Mai; Ben, Thomas; Wessels, François; Jones, Mark G.; Elkington, Paul; Wilkinson, Tom; Allenby, Mark C.; Daniels, T.; Dennison, Paddy; Lekkas, Anastasios; Land, D.V.; Freeman, Anna; Burke, Hannah; Faust, Saul N; Thomas, Gareth J.; Kipps, Christopher

doi:10.1016/j.bja.2020.07.008

Cited by 52 publications

(54 citation statements)

References 8 publications

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“…Our population consists of 96 critical COVID-19 patients with mean age 69.65 +/-14.33 years old, 28.9% of whom female, and 30.2% needed transfer to ICU, while 46.9% of the patients deceased. In our study mortality, despite being considerable, must be compared with other experiences of COVID-19 units dedicated to non-invasive ventilatory support, and mortality rates in studies that consider non-invasive ventilation treated COVID-19 patients vary from 45% of this large multicentered German study 7 to sensibly higher values (79%, 83.3%) of studies with smaller samples 8,9 . Aim of our study was to identify mortality prognostic features, possible gender-related differences and to identify ICU transfer prognostic factors.…”

Section: Discussionmentioning

confidence: 96%

Clinical Course, Risk Factors for Transfer to Icu and Mortality in Patients With Covid-19 Affected by Acute Respiratory Failure Referred to a Respiratory Intermediatate Care Unit

Buonamico

Vn²,

Boniello

et al. 2020

Preprint

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Introduction There are no clear guidelines as yet for the selection of patients affected by COVID-19 who can be treated in intermediate RICU, neither shared criteria for their intubation and transfer in ICU. In the present study we described the clinical course and risk factors for transfer to ICU and mortality of SARS-Cov-2 positive patients affected by acute respiratory failure, hospitalized in a Respiratory Intermediate Care Unit in the south of Italy. Methods In this retrospective, observational single centre study we evaluated 96 laboratory confirmed COVID-19 patients affected by acute respiratory failure (ARF). We compared demographic data, laboratory data and clinical outcomes between deceased and survived patients, aiming to identify risk factors for transfer to ICU and mortality, and possible gender-related differences. Results Of 96 patients, 51 (53.1%) survived and 45 (46.9 %) died. Among those who died, 23 (51.1%) deceased in RICU. Twenty-nine (30.2%) were transferred to ICU, of whom 22 (75.9%) died in ICU. Patients affected by COPD have a higher mortality compared to patients without this comorbidity (p=0.002). Lower baseline P/F ratio (p=0,014) and neurologic comorbidities (p=0,008) emerged as risk factors for death. Male were younger than female patients (66 vs 80 y.o.; p=0.042). In female patients, lower peripheral blood lymphocyte count (p=0.007) is a risk factor for death, characteristic gender-related in our sample. Female sex was a protective parameter against transfer to ICU (p=0,036) and P/F ratio was not a significant predictor of transfer to ICU (p=0,227). Only higher baseline CRP (p=0,034) has shown a predictive role for transfer to ICU in our sample. Patients deceased after a transfer to ICU had younger age (p=0,000), lower median comorbidity number (p=0,000), lower D-dimer (p=0,029) and lower prevalence of female sex (p=0,029). Discussion Mortality in our study was similar to that found in other studies involving patients in non-invasive ventilation. In our study older age and comorbidities play as predictors of death in COVID-19 patients. COPD, despite presenting low prevalence, is a risk factor for death, both in men and women. In female patients chronic ischemic heart disease and congestive heart failure are death predictors. High CRP and lymphopenia, linked to inflammatory status, are predictors of transfer to ICU. Patients transferred to ICU higher mortality than the others, and patients who die in ICU are mostly men, younger and have less comorbidities. Baseline P/F ratio is not a good predictor of transfer to ICU, while in our sample is a sensible predictor of death. More studies need to be performed on COVID-19 patients, in the urgency of COVID-19 pandemic persistence.

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Section: Discussionmentioning

confidence: 96%

Clinical Course, Risk Factors for Transfer to Icu and Mortality in Patients With Covid-19 Affected by Acute Respiratory Failure Referred to a Respiratory Intermediatate Care Unit

Buonamico

Vn²,

Boniello

et al. 2020

Preprint

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“…However, a small study on patients with influenza A on HFNC showed that 45% avoided intubation, although all of the patients with severe hypoxemia were eventually intubated ( 56 ). Some institutions are concerned that HFNC can aerosolize the virus, leading to possible exposure of health care workers, though early evidence suggests appropriate PPE is effective in mitigating this risk ( 57 , 58 , 59 ). Manikin studies suggest that the dispersal of liquid from HFNO at 60 L/min is minimal, and significantly less than that caused by coughing and sneezing, providing that nasal cannulae are well fitted ( 60 , 61 , 62 ).…”

Section: Discussionmentioning

confidence: 99%

“…A small study on patients with COVID-19 in Wuhan found that 72% of patients treated with NIPPV died, and the mortality rates were similarly high for those treated with NIPPV and intubation ( 8 ). More recent studies have shown patients with moderate-to-severe COVID-19 ARDS may be managed successfully on NIPPV alone, but these remain limited to small retrospective cohorts ( 58 , 66 ). NIPPV also aerosolizes the virus, and given the unclear benefit to patients with hypoxemic respiratory failure, it should not be a first-line treatment in most circumstances ( 57 , 67 ).…”

Section: Discussionmentioning

confidence: 99%

Emergency Department Management of Severe Hypoxemic Respiratory Failure in Adults With COVID-19

Wilcox

Condella

2021

The Journal of Emergency Medicine

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“…Deaths are only likely to occur if from nonrespiratory causes such as sepsis or nonrespiratory organ failure, otherwise they would have been escalated to IMV/ECMO. (10) Assume that CPAP can continue on the ward but double the mortality for reduces surrounding support etc.…”

Section: Niv/cpapmentioning

confidence: 99%

“…Observation from Sivaloganathan et al (10) Assume that CPAP can continue on the ward, but with an increase due to a reduction in other supportive care.…”

Section: Niv/cpap (Ceiling)mentioning

confidence: 99%

Construction of a demand and capacity model for intensive care and hospital ward beds, and mortality from COVID-19

McDonald

Martin

Bale

et al. 2021

Preprint

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BackgroundThis paper describes the construction of a model used to estimate the number of excess deaths that could be expected as a direct consequence of a lack of hospital bed and intensive care unit (ICU) capacity.MethodsA series of compartmental models was used to estimate the number of deaths under different combinations of care required (ICU or ward), and care received (ICU, ward or no care) in England up to the end of April 2021. Model parameters were sourced from publicly available government information, organisations collating COVID-19 data and calculations using existing parameters. A compartmental sub-model was used to estimate the mortality scalars that represent the increase in mortality that would be expected from a lack of provision of an ICU or general ward bed when one is required. Three illustrative scenarios for admissions numbers, ‘Optimistic’, ‘Middling’ and ‘Pessimistic’, are described showing how the model can be used to estimate mortality rates under different scenarios of capacity.ResultsThe key output of our collaboration was the model itself rather than the results of any of the scenarios. The model allows a user to understand the excess mortality impact arising as a direct consequence of capacity being breached under various scenarios or forecasts of hospital admissions. The scenarios described in this paper are illustrative and are not forecasts.There were no excess deaths from a lack of capacity in any of the ‘Optimistic’ scenario applications in sensitivity analysis.Several of the ‘Middling’ scenario applications under sensitivity testing resulted in excess deaths directly attributable to a lack of capacity. Most excess deaths arose when we modelled a 20% reduction compared to best estimate ICU capacity. This led to 597 deaths (0.7% increase).All the ‘Pessimistic’ scenario applications under sensitivity analysis had excess deaths. These ranged from 49,219 (19.4% increase) when we modelled a 20% increase in ward bed availability over the best-estimate, to 103,845 (40.9% increase) when we modelled a 20% shortfall in ward bed availability below the best-estimate. The emergence of a new, more transmissible variant (VOC 202012/01) increases the likelihood of real world outcomes at, or beyond, those modelled in our ‘Pessimistic’ scenario.The results can be explained by considering how capacity evolves in each of the scenarios. In the Middling scenario, whilst ICU capacity may be approached and even possibly breached, there remains sufficient ward capacity to take lives who need either ward or ICU support, keeping excess deaths relatively low. However, the Pessimistic scenario sees ward capacity breached, and in many scenarios for a period of several weeks, resulting in much higher mortality in those lives who require care but do not receive it.ConclusionsNo excess deaths from breaching capacity would be expected under the unadjusted ‘Optimistic’ assumptions of demand. The ‘Middling’ scenario could result in some excess deaths from breaching capacity, though these would be small (0.7% increase) relative to the total number of deaths in that scenario. The ‘Pessimistic’ scenario would certainly result in significant excess deaths from breaching capacity. Our sensitivity analysis indicated a range between 49,219 (19.4% increase) and 103,845 (40.9% increase) excess deaths.Without the new variant, exceeding capacity for hospital and ICU beds did not appear to be the most likely outcome but given the new variant it now appears more plausible and, if so, would result in a substantial increase in the number of deaths from COVID-19.

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Noninvasive ventilation for COVID-19-associated acute hypoxaemic respiratory failure: experience from a single centre

Cited by 52 publications

References 8 publications

Clinical Course, Risk Factors for Transfer to Icu and Mortality in Patients With Covid-19 Affected by Acute Respiratory Failure Referred to a Respiratory Intermediatate Care Unit

Clinical Course, Risk Factors for Transfer to Icu and Mortality in Patients With Covid-19 Affected by Acute Respiratory Failure Referred to a Respiratory Intermediatate Care Unit

Emergency Department Management of Severe Hypoxemic Respiratory Failure in Adults With COVID-19

Construction of a demand and capacity model for intensive care and hospital ward beds, and mortality from COVID-19

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