Mechanical Ventilation and Coronavirus Disease 2019: A Case-Control Analysis of Clinical Characteristics, Lung Mechanics, and Mortality

Abstract

Objectives: To investigate the differences in clinical course, ventilator mechanics, and outcomes of patients with coronavirus disease 2019 secondary to acute respiratory distress syndrome infection compared with a historical cohort of acute respiratory distress syndrome. Design: Comparative case-control study. Setting: Multicenter, comprehensive tertiary healthcare facility in Detroit, MI. Patients/Subjects: Adult patients hospitalized with coronavirus disease 2019 secondary to acute respiratory distress syndrome infection were compared with patients hospitalized with acute respiratory distress syndrome prior to the coronavirus disease 2019 pandemic (control). Interventions: None. MEASUREMENTS AND Main Results: We included 384 patients in the analysis. Inpatient mortality was significantly higher in patients with coronavirus disease 2019 secondary to acute respiratory distress syndrome infection compared with controls (64% vs 49%; p = 0.007). Despite both groups demonstrating similar ventilatory function and Sequential Organ Failure Assessment score on day 1 of intubation, with similar lung compliance throughout the study period, patients with coronavirus disease 2019 secondary to acute respiratory distress syndrome infection demonstrated progressive hypoxia compared with controls across the study period. Similarly, higher positive end-expiratory pressure levels and increased use of paralytics were observed in the patients with coronavirus disease 2019 secondary to acute respiratory distress syndrome infection group. On univariate analysis of the entire cohort, significant risk factors for inpatient mortality included coronavirus disease 2019 infection (p = 0.007), older age (p < 0.001), high Sequential Organ Failure Assessment score (p = 0.003), vasopressor use (p = 0.039), paralytic use (p < 0.001), higher positive end-expiratory pressure levels on day 3 (p = 0.027) and day 7 (p < 0.001), in addition to acute respiratory distress syndrome severity on both days 3 (p = 0.008) and 7 (p < 0.001). Multivariate analysis identified coronavirus disease 2019 infection (odds ratio, 1.939; p = 0.021), older age (odds ratio, 1.042; p < 0.001), paralytic use (odds ratio, 3.366; p < 0.001), and higher Sequential Organ Failure Assessment score (odds ratio, 1.152; p = 0.027) as significant predictors of mortality across the entire cohort. Conclusions: Patients with coronavirus disease 2019 secondary to acute respiratory distress syndrome infection demonstrated higher mortality compared with control patients hospitalized with acute respiratory distress syndrome prior to the pandemic, with progressive hypoxia throughout the study period, despite similar lung mechanics and initial Sequential Organ Failure Assessment score. Coronavirus disease 2019 infection, older age, paralytic use, and higher Sequential Organ Failure Assessment scores were independent risk factors for 28-day mortality across the entire cohort.

Tocilizumab Associated With Survival in Patients Hospitalized for COVID-19 Acute Respiratory Distress Syndrome and Low Urine Output

“…In prior studies, mortality was noted to be 25% in patients with ARDS and normal urine output but 60% in patients with ARDS and oliguria. 4 Compared to historic ARDS cohorts, COVID-19 ARDS demonstrated a higher mortality of close to 65% 8 while patients with COVID-19 admitted to the ICU demonstrated mortality of 40% overall during early stages of the pandemic. 22 Additionally, tocilizumab has been associated with improved survival (adjusted odds ratio [OR] 0.296, 95% confidence interval [CI]: 0.098-0.889) in previous studies at our institution.…”

“…5,6 With infectious pneumonia recognized as the most common cause of ARDS, 7 COVID-19 resulted in an overwhelming majority of ARDS cases during the pandemic and was associated with high overall mortality in the critically ill population. 8 Prior investigations have also suggested that patients with COVID-19 ARDS suffer from a higher incidence of renal disease and worse hypoxemia after intubation, despite clinically similar ventilator mechanics compared to historical cohorts of ARDS. 8,9 Chand et al 10 identified a 90% incidence of ARDS and 76.7% incidence of AKI in a critically ill cohort of patients with COVID-19, much higher than suggested by previous reports.…”

“…8 Prior investigations have also suggested that patients with COVID-19 ARDS suffer from a higher incidence of renal disease and worse hypoxemia after intubation, despite clinically similar ventilator mechanics compared to historical cohorts of ARDS. 8,9 Chand et al 10 identified a 90% incidence of ARDS and 76.7% incidence of AKI in a critically ill cohort of patients with COVID-19, much higher than suggested by previous reports. 3 Integral to the development of AKI in the setting of ARDS is the pro-inflammatory cytokine, interleukin-6 (IL-6).…”