Feasibility and clinical impact of out-of-ICU noninvasive respiratory support in patients with COVID-19-related pneumonia

Abstract

IntroductionThe Coronavirus 2(SARS-CoV-2) outbreak spread rapidly in Italy and the lack of intensive care unit(ICU) beds soon became evident, forcing the application of noninvasive respiratory support(NRS) outside the ICU, raising concerns over staff contamination. We aimed to analyse the safety of the hospital staff, the feasibility, and outcomes of NRS applied to patients outside the ICU.MethodsIn this observational study, data from 670 consecutive patients with confirmed COVID-19 referred to the Pulmonology Units in nine hospitals between March 1st and May 10th,2020 were analysed. Data were collected including medication, mode and usage of the NRS (i.e. high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), noninvasive ventilation(NIV)), length of stay in hospital, endotracheal intubation(ETI) and deaths.ResultsForty-two health-care workers (11.4%) tested positive for infection, but only three of them required hospitalisation. Data are reported for all patients (69.3% male), whose mean age was 68 (sd 13) years. The PaO2/FiO2 ratio at baseline was 152±79, and the majority of patients (49.3%) were treated with CPAP. The overall unadjusted 30-day mortality rate was 26.9% with 16%, 30%, and 30%, while the total ETI rate was 27% with 29%, 25% and 28%, for HFNC, CPAP, and NIV, respectively, and the relative probability to die was not related to the NRS used after adjustment for confounders. ETI and length of stay were not different among the groups. Mortality rate increased with age and comorbidity class progression.ConclusionsThe application of NRS outside the ICU is feasible and associated with favourable outcomes. Nonetheless, it was associated with a risk of staff contamination.

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

“…In our study cohort, the intubation rate was 45%, also taking into account those patients (n = 30) excluded from the study because intubated on the same day CPAP was started. This intubation rate is similar to that observed in non-COVID-19 ARF patients treated with NPPV, 26 but almost twice as high as that reported by two large studies on CPAP-treated COVID-19 patients (25% 4 and 22% 5 ), comprising both “do-not-intubate” and “candidate for intubation” patients. In the cohort of patients included in the study by Franco et al, 4 the severity of hypoxemic ARF, as assessed by PaO 2 /FiO 2 is lower than in our investigation, which might explain the lower rate of CPAP failure.…”

“…More recently, a multicentre observational study has shown that CPAP along with HFNC and NPPV can be readily applied outside of the ICU environment during COVID-19. 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.…”

Impact of an Intermediate Respiratory Care Unit on Clinical Outcomes of COVID-19 Patients

“…However, data is scarce regarding the impact of IMCU on mortality of severe COVID-19 patients. In this regard, Franco et al observed that the implementation of non-invasive respiratory support outside the ICU had favorable results, with an overall mortality rate of 26.9% (22). Similarly, we observed that mortality in IMCU patients who did not require ICU admission was 24.2%, signi cantly lower than in the ICU group.…”

Non-invasive respiratory support paths in hospitalized patients with COVID-19: proposal of an algorithm

“…Recent experience in COVID-19 related Acute respiratory failure (21 publications including 1553 patients) 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 with HFNC, CPAP and Bi-Level Ventilation (using negative pressure rooms in only one series 15 ) shows average success of 60%, 55% and 59%, respectively, and an average infection rate in health professionals of 5.2%, less than the 12% reported in New York City among the staff not necessarily working with NIRT. 28 …”