Outcomes of COVID-19 patients treated with continuous positive airway pressure outside the intensive care unit

Abstract

AimWe aim at characterising a large population of Coronavirus 19 (COVID-19) patients with moderate-to-severe hypoxemic acute respiratory failure (ARF) receiving CPAP outside intensive care unit (ICU), and ascertaining whether the duration of CPAP application increased the risk of mortality for patients requiring intubation.MethodsIn this retrospective, multicentre cohort study, we included COVID-19 adult patients, treated with CPAP outside ICU for hypoxemic ARF from March 1st to April 15th, 2020. We collected demographic and clinical data, including CPAP therapeutic goal, hospital length of stay (LOS), and 60-day in-hospital mortality.ResultsThe study includes 537 patients with a median age of 69 (IQR, 60–76) years. Males were 391 (73%). According to predefined CPAP therapeutic goal, 397 (74%) patients were included in full treatment subgroup, and 140 (26%) in the do-not intubate (DNI) subgroup. Median CPAP duration was 4 (IQR, 1–8) days, while hospital LOS 16 (IQR, 9–27) days. Sixty-day in-hospital mortality was overall 34% (95%CI, 0.304–0.384), and 21% (95%CI, 0.169–0.249) and 73% (95%CI, 0.648–0.787) for full treatment and DNI subgroups, respectively. In the full treatment subgroup, in-hospital mortality was 42% (95%CI, 0.345–0.488) for 180 (45%) CPAP failures requiring intubation, while 2% (95%CI, 0.008–0.035) for the remaining 217 (55%) patients who succeeded. Delaying intubation was associated with increased mortality [HR, 1.093 (95%CI, 1.010–1.184)].ConclusionsWe described a large population of COVID-19 patients treated with CPAP outside ICU. Intubation delay represents a risk factor for mortality. Further investigation is needed for early identification of CPAP failures.

Predictors of intubation in COVID-19 patients treated with out-of-ICU continuous positive airway pressure

“…As previously described, 6 CPAP was delivered through helmets (Intersurgical, Mirandola (MO), Italy; Dimar, Medolla, MO, Italy) through flowmeter (60−70 L/min) and face masks (Intersurgical, Mirandola, MO, Italy; Dimar, Medolla, MO, Italy; Fisher&Paykel, Auckland, New Zealand; ResMed, San Diego, CA, USA; Philips Respironics, Murrysville, PA, USA) via flowmeters or Boussignac systems (typically 30−70 L/min). FiO 2 was set by regulating oxygen and air flow.…”

“…As previously described, 6 respiratory intermediate care units were organized as follows. The nurse-to-patient ratio varied from a maximum of 1:6 both during day and night to a minimum of 1:8 and 1:12 during day and night, respectively.…”

“… 4 However, intubation after CPAP failure has been shown to occur in 22–25% 5 of patients, and other studies on noninvasive ventilation have reported that delayed intubation might worsen patient survival. 6 For this reason, the use of CPAP in COVID-19 patients is still under debate. Hence, the identification of early predictors of CPAP failure represents an urgent unmet clinical need.…”

Outcomes and characteristics of COVID-19 patients treated with continuous positive airway pressure/high-flow nasal oxygen outside the intensive care setting

“…There was no difference in time from hospitalisation to initiation of CPAP/HFNO between survivors and non-survivors (median time to initiation [range] 2 days [1-30] vs 2 days [1][2][3][4][5][6][7][8][9][10][11][12][13][14]). The median duration of CPAP/HFNO treatment for all patients was 3.5 days (range 1 -24); there was no difference between survivors and non-survivors (median [range] = 4 [1-24] days vs. 3.5 [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] days, p=0.454).…”

“…The role of these non-invasive therapies has been examined in previous studies (2)(3)(4)(5) with variation in the reported outcomes. Predominantly these report outcomes from inside intensive care units, however, there is also data from patients treated outside of this setting (6)(7)(8).…”