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

Cosimo Franco, Nicola Facciolongo, Roberto Tonelli, Roberto Dongilli, Andrea Vianello, Lara Pisani, Raffaele Scala, Mario Malerba, Annalisa Carlucci, Emanuele Alberto Negri, Greta Spoladore, Giovanna Arcaro, Paolo Amedeo Tillio, Cinzia Lastoria, Gioachino Schifino, Luca Tabbì, Luca Guidelli, Giovanni Guaraldi, V Marco Ranieri, Enrico Clini, Stefano Nava, Cosimo Franco, Nicola Facciolongo, Roberto Tonelli, Roberto Dongilli, Andrea Vianello, Lara Pisani, Raffaele Scala, Mario Malerba, Annalisa Carlucci, Emanuele Alberto Negri, Greta Spoladore, Giovanna Arcaro, Paolo Amedeo Tillio, Cinzia Lastoria, Gioachino Schifino, Luca Tabbì, Luca Guidelli, Giovanni Guaraldi, V Marco Ranieri, Enrico Clini, Stefano Nava

Abstract

Introduction: The severe acute respiratory syndrome-coronavirus 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 and the feasibility and outcomes of NRS applied to patients outside the ICU.

Methods: In this observational study, data from 670 consecutive patients with confirmed coronavirus disease 2019 referred to pulmonology units in nine hospitals between March 1 and May 10, 2020 were analysed. Data collected included medication, mode and usage of 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.

Results: 42 (11.1%) healthcare workers tested positive for infection, but only three of them required hospitalisation. Data are reported for all patients (69.3% male), whose mean±sd age was 68±13 years. The arterial oxygen tension/inspiratory oxygen fraction ratio at baseline was 152±79, and the majority (49.3%) of patients were treated with CPAP. The overall unadjusted 30-day mortality rate was 26.9%, with 16%, 30% and 30% for HFNC, CPAP and NIV, respectively, while the total ETI rate was 27%, with 29%, 25% and 28%, respectively; the relative probability of death 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.

Conclusions: The application of NRS outside the ICU is feasible and associated with favourable outcomes. Nonetheless, it was associated with a risk of staff contamination.

Conflict of interest statement

Conflict of interest: C. Franco has nothing to disclose. Conflict of interest: N. Faccialongo has nothing to disclose. Conflict of interest: R. Tonelli has nothing to disclose. Conflict of interest: R. Dongilli has nothing to disclose. Conflict of interest: A. Vianello has nothing to disclose. Conflict of interest: L. Pisani has nothing to disclose. Conflict of interest: R. Scala has nothing to disclose. Conflict of interest: M. Malerba has nothing to disclose. Conflict of interest: A. Carlucci has nothing to disclose. Conflict of interest: E.A. Negri has nothing to disclose. Conflict of interest: G. Spoladore has nothing to disclose. Conflict of interest: G. Arcaro has nothing to disclose. Conflict of interest: P.A. Tillio has nothing to disclose. Conflict of interest: C. Lastoria has nothing to disclose. Conflict of interest: G. Schifino has nothing to disclose. Conflict of interest: L. Tabbì has nothing to disclose. Conflict of interest: L. Guidelli has nothing to disclose. Conflict of interest: G. Guaraldi has nothing to disclose. Conflict of interest: V.M. Ranieri has nothing to disclose. Conflict of interest: E. Clini has nothing to disclose. Conflict of interest: S. Nava has nothing to disclose.

Copyright ©ERS 2020.

Figures

FIGURE 1
FIGURE 1
Patient allocation to noninvasive respiratory support (NRS) and related clinical outcomes. COVID-19: coronavirus disease 2019; ARF: acute hypoxic respiratory failure; ICU: intensive care unit; CPAP: continuous positive airway pressure; DNI: do-not-intubate order; ETI: endotracheal intubation; SB: spontaneous breathing; HFNC: high-flow nasal cannula; NIV: noninvasive mechanical ventilation.

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Source: PubMed

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