Breathing pattern, accessory respiratory muscles work, and gas exchange evaluation for prediction of NIV failure in moderate-to-severe COVID-19-associated ARDS after deterioration of respiratory failure outside ICU: the COVID-NIV observational study

Andrey I Yaroshetskiy, Zamira M Merzhoeva, Natalia A Tsareva, Natalia V Trushenko, Galia S Nuralieva, Vasily D Konanykhin, Anna P Krasnoshchekova, Sergey N Avdeev, Andrey I Yaroshetskiy, Zamira M Merzhoeva, Natalia A Tsareva, Natalia V Trushenko, Galia S Nuralieva, Vasily D Konanykhin, Anna P Krasnoshchekova, Sergey N Avdeev

Abstract

Background: Data on the efficacy of non-invasive ventilation (NIV) after progression of respiratory failure in patients who have already received oxygen therapy, or CPAP outside ICU is limited. The study aimed to find predictors of NIV failure based on breathing pattern, gas exchange, and accessory respiratory muscles evaluation in patients who progressed to moderate-to-severe COVID-19 ARDS.

Methods: This was a prospective observational study in patients with moderate-to-severe COVID-19-ARDS on NIV (n = 80) admitted to COVID-ICU of Sechenov University. The combined success rate for conventional oxygen and CPAP outside ICU was 78.6% (440 of 560 patients). The primary endpoints were intubation rate and mortality. We measured respiratory rate, exhaled tidal volume (Vte), mean peak inspiratory flow (PIF), inspiratory time (Ti), PaO2, SpO2, end-tidal carbon dioxide (PETCO2), and Patrick score, and calculated ROX index, PaO2/FiO2, ventilatory ratio, and alveolar dead space (Vdalv/Vt) on Days 1, 3, 5, 7, 10, and 14. For all significant differences between NIV success and failure groups in measured data, we performed ROC analysis.

Results: NIV failure rate in ICU after deterioration of respiratory failure outside ICU was 71.3% (n = 57). Patients with the subsequent NIV failure were older at inclusion, more frail, had longer duration of disease before ICU admission, and higher rate of CPAP use outside ICU. ROC-analysis revealed that the following respiratory parameters after 48 h of NIV can serve as a predictors for NIV failure in moderate-to-severe COVID-19-associated ARDS: PaO2/FiO2 < 112 mmHg (AUROC 0.90 (0.93-0.97), p < 0.0001); PETCO2 < 19.5 mmHg (AUROC 0.84 (0.73-0.94), p < 0.0001); VDalv/VT > 0.43 (AUROC 0.78 (0.68-0.90), p < 0.0001); ROX-index < 5.02 (AUROC 0.89 (0.81-0.97), p < 0.0001); Patrick score > 2 points (AUROC 0.87 (0.78-0.96), p = 0.006).

Conclusion: In patients who progressed to moderate-to-severe COVID-19-ARDS probability of NIV success rate was about 1/3. Prediction of the NIV failure can be made after 48 h based on ROX index < 5.02, PaO2/FiO2 < 112 mmHg, PETCO2 < 19.5 mmHg, and Patrick score > = 2.

Trial registration: ClinicalTrials.gov identifier: NCT04667923 , registered on 16/12/2020.

Keywords: ARDS; Accessory respiratory muscles; Alveolar dead space; COVID-19; NIV; Noninvasive ventilation; ROX-index.

Conflict of interest statement

AIY reported personal fees from GE, Philips Respironics, Covidien, Fisher & Paykel, Drager, Triton Electronics, Mindray, Pfizer, BBraun, Gilead outside the submitted work. SNA reported personal fees from Behringer Ingelheim, Pfizer, Novartis, AstraZeneca, Chiesi outside the submitted work. No other disclosers were reported.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
The study cohort selection
Fig. 2
Fig. 2
Clinical frailty score in NIV success (green) and NIV failure (blue) groups
Fig. 3
Fig. 3
The gas exchange and respiratory pattern in NIV success and NIV failure groups during 14 days. A PaO2/FiO2. B Respiratory Rate. C ROX index. D End-tidal carbon dioxide. E Alveolar dead space to tidal volume ratio. F Patrick score. Data on NIV success (green) and NIV failure (blue) are presented as medians and 95% confidence intervals (A-E), boxplots (F). The x-axis represents days after initiation of non-invasive ventilation. Abbreviations: PaO2- partial pressure of oxygen in arterial blood; FiO2—inspiratory oxygen fraction; VDalv—alveolar dead space; VT- tidal volume; PetCO2—end-tidal partial pressure of carbon dioxide. * p-value < 0.05, comparison between NIV success and NIV failure groups (Mann-Whitney U test). ** p-value < 0.01, comparison between NIV success and NIV failure groups (Mann-Whitney U test). § p-value < 0.001, comparison between NIV success and NIV failure groups (Mann-Whitney U test)
Fig. 4
Fig. 4
Prediction of NIV failure after 48 h basing on gas exchange and respiratory pattern parameters (ROC curves). A PaO2/FiO2. B Respiratory Rate. C ROX index. D End-tidal carbon dioxide. E Alveolar dead space to tidal volume ratio. F Patrick score. Abbreviations: PaO2- partial pressure of oxygen in arterial blood; FiO2—inspiratory oxygen fraction; VDalv—alveolar dead space; VT- tidal volume; PetCO2- end-tidal partial pressure of carbon dioxide
Fig. 5
Fig. 5
Prediction of NIV failure after 48 h basing on gas exchange and respiratory pattern parameters (Odds ratios). Data presented as odds ratio and 95% confidence interval. Abbreviations: PaO2- partial pressure of oxygen in arterial blood; FiO2—inspiratory oxygen fraction; VDalv—alveolar dead space; VT- tidal volume; PetCO2- end-tidal partial pressure of carbon dioxide, RR—respiratory rate

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