Noninvasive ventilation in COVID-19 patients aged ≥ 70 years—a prospective multicentre cohort study

Abstract

Background Noninvasive ventilation (NIV) is a promising alternative to invasive mechanical ventilation (IMV) with a particular importance amidst the shortage of intensive care unit (ICU) beds during the COVID-19 pandemic. We aimed to evaluate the use of NIV in Europe and factors associated with outcomes of patients treated with NIV. Methods This is a substudy of COVIP study—an international prospective observational study enrolling patients aged ≥ 70 years with confirmed COVID-19 treated in ICU. We enrolled patients in 156 ICUs across 15 European countries between March 2020 and April 2021.The primary endpoint was 30-day mortality. Results Cohort included 3074 patients, most of whom were male (2197/3074, 71.4%) at the mean age of 75.7 years (SD 4.6). NIV frequency was 25.7% and varied from 1.1 to 62.0% between participating countries. Primary NIV failure, defined as need for endotracheal intubation or death within 30 days since ICU admission, occurred in 470/629 (74.7%) of patients. Factors associated with increased NIV failure risk were higher Sequential Organ Failure Assessment (SOFA) score (OR 3.73, 95% CI 2.36–5.90) and Clinical Frailty Scale (CFS) on admission (OR 1.46, 95% CI 1.06–2.00). Patients initially treated with NIV (n = 630) lived for 1.36 fewer days (95% CI − 2.27 to − 0.46 days) compared to primary IMV group (n = 1876). Conclusions Frequency of NIV use varies across European countries. Higher severity of illness and more severe frailty were associated with a risk of NIV failure among critically ill older adults with COVID-19. Primary IMV was associated with better outcomes than primary NIV. Clinical Trial RegistrationNCT04321265, registered 19 March 2020, https://clinicaltrials.gov.

Outcomes of patients aged ≥80 years with respiratory failure initially treated with non-invasive ventilation in European intensive care units before and during COVID-19 pandemic

“…In this subgroup the 30-day mortality reached nearly 50% in non-COVID patients and more than 70% in patients with COVID-19. This may be a least partially related to longer exposure to NIV which is associated with patient self-inflicted lung injury potentially leading to worse outcomes [ 7 , 28 ]. On the other hand, our analyses showed that the 30-day mortality of patients who required invasive mechanical ventilation was similar regardless of previous NIV attempt in both cohorts while some previous studies showed that early intubation may even be associated with worse outcomes [ 29 ].…”

“…The frequency of NIV failure in patients with non-COVID ARDS was relatively high and correlated with ARDS severity [ 6 ]. Initial reports confirmed NIV to have a low success rate in the treatment of hypoxemic respiratory failure due to COVID-19 [ 6 , 7 ]. Randomised controlled trials showed, albeit inconsistently, that NIV compared to high-flow oxygen therapy and conventional oxygen therapy reduced the need for intubation but did not reduce mortality [ 8 – 10 ].…”

Timing of Intubation in COVID-19: When It Is Too Early and When It Is Too Late

“…The failure of "very early" intubation at the outset of the pandemic, and the subsequent overestimated mortality from using IMV, likely led to significantly increased use of NIV and HFNO for longer durations to avoid intubation. However, accumulating evidence suggests "delaying" intubation in patients with COVID-19-associated respiratory failure is also associated with a higher mortality (21)(22)(23)(24)(25). In a cohort of 574 ICU patients with COVID-19, "very late" intubation (beyond 5 d of HFNO or NIV initiation) had Commentary the rate of mortality (87%) (26).…”

Authors` response to “Efficacy of noninvasive ventilation in patients with COVID-19”

“…We thank Shen and colleagues for their interest in our paper on the use of noninvasive ventilation in older adults with COVID-19 [ 1 ].…”