Background: The SARS-CoV-2 outbreak spread in Lombardy Region (Italy) rapidly saturating intensive care unit beds, forcing the application of noninvasive respiratory support in RICU. Objectives: We aimed to analyze the effects of helmet CPAP in COVID19- related ARDS in RICU. The primary outcome was CPAP failure, defined as the occurrence of either intubation or death due to any cause during RICU stay; the secondary one was the identification of factors related to patients’ prognosis. Methods: 150 consecutive patients with ARDS due to COVID-19 and referred to Vimercate Hospital (MB) between March and May 2020 were enrolled. All patients were treated with helmet CPAP. Demographics, clinical and laboratory tests and blood gas analysis were collected. Results: Patients had a mean (SD) age of 62 (±11) years. The worst PaO2/ FiO2 ratio during continuous positive airway pressure stratified the subjects in mild (26/150), moderate (39/150) and severe (85/150) ARDS. Most of patients were treated with systemic corticosteroids (79%). 93 patients (62%) were successfully treated while 57 (38%) failed; of the latter, 32 patients were transferred in the intensive care unit to receive invasive mechanical ventilation. Dimer test and ferritin at admission, use of steroids, P/F in oxygen at admission and age were independently associated with CPAP failure. The severity of ARDS and the use of steroids strongly correlate with clinical outcomes. Mortality rate in our cohort of patients was 28%. Conclusions: The application of helmet CPAP in RICU and the administration of corticosteroids in COVID19-related ARDS are associated with satisfactory clinical outcomes.

In polypathological patients an early diagnosis of respiratory failure is often difficult. Frequently, polypathology does not allow intubation and intensive care unit (ICU) treatment with invasive mechanical ventilation (IMV). Non-invasive ventilation (NIV) and admission to respiratory intermediate care unit (RICU) may be the only option in these cases. Presepsin, a new predictive marker of systemic infection, appears particularly usefull for early diagnosis, treatment and prognosis of sepsis. 1.2. Case A 73-year-old man with a previous history of ischemic heart disease undergoing coronary artery bypass grafting (CABG), residual constrictive pericarditis, previous multiple hospitalizations for heart failure (CHF), autoimmune hemolytic anemia on chronic steroid therapy and cognitive impairment arrived to the Emergency Department (ED) in acute global respiratory failure with severe acidosis; he was normothermic, radiological imaging showed aspecific diffuse parenchymal thickening and traditional inflammatory markers (white blood cell - WBC - count and serum level of C-reactive protein - CPR - and procalcitonin - PCT) were in normal range, but blood tests revealed a marked elevation in the value of presepsin. Intensivist’s evaluation concluded for a do-not intubate (DNI) status and the patient was admitted to RICU. The combined treatment with NIV, broad-spectrum antibiotics and dopamine resulted in a progressive improvement of the clinical, laboratoristic and radiological parameters and the subsequent discharge of the patient to home in satisfactory general condition. 1.3. Conclusions Elevated presepsin level was found to be an early predictor of severe sepsis, ofter preceding other laboratory or clinical signs of infection. NIV in RICU and medical therapy allowed the successful treatment of a severe global respiratory failure in a DNI patient.