Implications of early respiratory support strategies on disease progression in critical COVID-19: a matched subanalysis of the prospective RISC-19-ICU cohort

Publication

Implications of early respiratory support strategies on disease progression in critical COVID-19: a matched subanalysis of the prospective RISC-19-ICU cohort

Journal Paper/Review - May 25, 2021

RISC-19-ICU Investigators, Selz Daniela, Stephan Michael, Studhalter Michael, Redecker Hermann, Hübner Tobias, Marquardt Katharina, Ceruti Samuele, Baltussen Weber Anja, Perez Marie-Helene, Fleisch Isabelle, Marrel Julien, Bürkle Christian, Grazioli Serge, Cereghetti Sara, Pietsch Urs, Ristic Anette, Roche-Campo Ferran, Hilty Matthias P, Schuepbach Reto A, Guerci Philippe, Montomoli Jonathan, Fumeaux Thierry, Heuberger Dorothea M, Colak Elif, Haberthuer Christoph, Gaspert Tomislav, Fodor Patricia, Franchitti Laurent Marilene, Meyer Zu Bentrup Friederike, Heise Antje, Ksouri Hatem, Dullenkopf Alexander, Hillgaertner Frank, Potalivo Antonella, Turrini Fabrizio, Colombo Riccardo, Wu Maddalena A, Kleger Gian-Reto, Fogagnolo Alberto, Korsos Anita, Wengenmayer Tobias, Tschoellitsch Thomas, David Sascha, Yuen Bernd, Alfaro-Farias Mario, Buehler Philipp K, Aguirre-Bermeo Hernán, Rezoagli Emanuele, Rodríguez-García Raquel, Salomon Petra, Laube Marcus, Jeitziner Marie M, Wiegand Jan, Merki Lukas, Siegemund Martin, Schott Peter, Gehring Nadine, Michot Marc P, Ensner Rolf, Lozano-Gómez Herminia, Martín-Delgado Maria C, Lander-Azcona Arantxa, Castro Pedro, Wendel Garcia Pedro D

Citation

RISC-19-ICU Investigators, Selz D, Stephan M, Studhalter M, Redecker H, Hübner T, Marquardt K, Ceruti S, Baltussen Weber A, Perez M, Fleisch I, Marrel J, Bürkle C, Grazioli S, Cereghetti S, Pietsch U, Ristic A, Roche-Campo F, Hilty M, Schuepbach R, Guerci P, Montomoli J, Fumeaux T, Heuberger D, Colak E, Haberthuer C, Gaspert T, Fodor P, Franchitti Laurent M, Meyer Zu Bentrup F, Heise A, Ksouri H, Dullenkopf A, Hillgaertner F, Potalivo A, Turrini F, Colombo R, Wu M, Kleger G, Fogagnolo A, Korsos A, Wengenmayer T, Tschoellitsch T, David S, Yuen B, Alfaro-Farias M, Buehler P, Aguirre-Bermeo H, Rezoagli E, Rodríguez-García R, Salomon P, Laube M, Jeitziner M, Wiegand J, Merki L, Siegemund M, Schott P, Gehring N, Michot M, Ensner R, Lozano-Gómez H, Martín-Delgado M, Lander-Azcona A, Castro P, Wendel Garcia P. Implications of early respiratory support strategies on disease progression in critical COVID-19: a matched subanalysis of the prospective RISC-19-ICU cohort. Crit Care 2021; 25:175.

Type

Journal Paper/Review (English)

Journal

Crit Care 2021; 25

Publication Date

May 25, 2021

Issn Electronic

1466-609X

Pages

175

Brief description/objective

BACKGROUND
Uncertainty about the optimal respiratory support strategies in critically ill COVID-19 patients is widespread. While the risks and benefits of noninvasive techniques versus early invasive mechanical ventilation (IMV) are intensely debated, actual evidence is lacking. We sought to assess the risks and benefits of different respiratory support strategies, employed in intensive care units during the first months of the COVID-19 pandemic on intubation and intensive care unit (ICU) mortality rates.

METHODS
Subanalysis of a prospective, multinational registry of critically ill COVID-19 patients. Patients were subclassified into standard oxygen therapy ≥10 L/min (SOT), high-flow oxygen therapy (HFNC), noninvasive positive-pressure ventilation (NIV), and early IMV, according to the respiratory support strategy employed at the day of admission to ICU. Propensity score matching was performed to ensure comparability between groups.

RESULTS
Initially, 1421 patients were assessed for possible study inclusion. Of these, 351 patients (85 SOT, 87 HFNC, 87 NIV, and 92 IMV) remained eligible for full analysis after propensity score matching. 55% of patients initially receiving noninvasive respiratory support required IMV. The intubation rate was lower in patients initially ventilated with HFNC and NIV compared to those who received SOT (SOT: 64%, HFNC: 52%, NIV: 49%, p = 0.025). Compared to the other respiratory support strategies, NIV was associated with a higher overall ICU mortality (SOT: 18%, HFNC: 20%, NIV: 37%, IMV: 25%, p = 0.016).

CONCLUSION
In this cohort of critically ill patients with COVID-19, a trial of HFNC appeared to be the most balanced initial respiratory support strategy, given the reduced intubation rate and comparable ICU mortality rate. Nonetheless, considering the uncertainty and stress associated with the COVID-19 pandemic, SOT and early IMV represented safe initial respiratory support strategies. The presented findings, in agreement with classic ARDS literature, suggest that NIV should be avoided whenever possible due to the elevated ICU mortality risk.