Clinical features, ventilatory management, and outcome of ARDS caused by COVID-19 are similar to other causes of ARDS
Carlos Ferrando, Fernando Suarez-Sipmann, Ricard Mellado-Artigas, María Hernández, Alfredo Gea, Egoitz Arruti, César Aldecoa, Graciela Martínez-Pallí, Miguel A Martínez-González, Arthur S Slutsky, Jesús Villar, COVID-19 Spanish ICU Network
Abstract
Purpose: The main characteristics of mechanically ventilated ARDS patients affected with COVID-19, and the adherence to lung-protective ventilation strategies are not well known. We describe characteristics and outcomes of confirmed ARDS in COVID-19 patients managed with invasive mechanical ventilation (MV).
Methods: This is a multicenter, prospective, observational study in consecutive, mechanically ventilated patients with ARDS (as defined by the Berlin criteria) affected with with COVID-19 (confirmed SARS-CoV-2 infection in nasal or pharyngeal swab specimens), admitted to a network of 36 Spanish and Andorran intensive care units (ICUs) between March 12 and June 1, 2020. We examined the clinical features, ventilatory management, and clinical outcomes of COVID-19 ARDS patients, and compared some results with other relevant studies in non-COVID-19 ARDS patients.
Results: A total of 742 patients were analysed with complete 28-day outcome data: 128 (17.1%) with mild, 331 (44.6%) with moderate, and 283 (38.1%) with severe ARDS. At baseline, defined as the first day on invasive MV, median (IQR) values were: tidal volume 6.9 (6.3-7.8) ml/kg predicted body weight, positive end-expiratory pressure 12 (11-14) cmH2O. Values of respiratory system compliance 35 (27-45) ml/cmH2O, plateau pressure 25 (22-29) cmH2O, and driving pressure 12 (10-16) cmH2O were similar to values from non-COVID-19 ARDS patients observed in other studies. Recruitment maneuvers, prone position and neuromuscular blocking agents were used in 79%, 76% and 72% of patients, respectively. The risk of 28-day mortality was lower in mild ARDS [hazard ratio (RR) 0.56 (95% CI 0.33-0.93), p = 0.026] and moderate ARDS [hazard ratio (RR) 0.69 (95% CI 0.47-0.97), p = 0.035] when compared to severe ARDS. The 28-day mortality was similar to other observational studies in non-COVID-19 ARDS patients.
Conclusions: In this large series, COVID-19 ARDS patients have features similar to other causes of ARDS, compliance with lung-protective ventilation was high, and the risk of 28-day mortality increased with the degree of ARDS severity.
Trial registration: ClinicalTrials.gov NCT04368975.
Keywords: Acute respiratory distress syndrome; Coronavirus; Mechanical ventilation; Outcome.
Conflict of interest statement
The authors declare no conflicts of interest in relation to this manuscript.
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References
- Wenjie T, Xiang Z, Xuejun M, et al. (2020) A novel coronavirus genome identified in a cluster of pneumonia cases—Wuhan, China 2019−2020. . Accessed 03 July 2020
- Grasselli G, Pesenti A, Cecconi M. Critical care utilization for the COVID-19 outbreak in Lombardy, Italy: early experience and forecast during an emergency response. JAMA. 2020 doi: 10.1001/jama.2020.4031.
- Ruan Q, Yang K, Wang W, et al. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan. China Intensive Care Med. 2020;46:846–848. doi: 10.1007/s00134-020-05991-x.
- The COVID-19 Lombardy ICU Network Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region, Italy. JAMA. 2020;323:1574–1581. doi: 10.1001/jama.2020.5394.
- Huang C, Yeming W, Xingwang L, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497–506. doi: 10.1016/S0140-6736(20)30183-5.
- Gattinoni L, Coppola S, Cressoni M. Covid-19 does not lead to a “typical” acute respiratory distress syndrome. Am J Respir Crit Care Med. 2020;201:1299–1300. doi: 10.1164/rccm.202003-0817LE.
- Gattinoni L, Chiumello E, Caironi P, et al. COVID-19 pneumonia: different respiratory treatment for different phenotypes? Intensive Care Med. 2020;46:1099–1102. doi: 10.1007/s00134-020-06033-2.
- Marini JJ, Gattinoni L. Management of COVID-19 respiratory distress. JAMA. 2020 doi: 10.1001/jama.2020.6825.
- Ranieri VM, Rubenfeld GD, Thompson BT, ARDS Definition Task Force et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307:2526–2533. doi: 10.1001/jama.2012.5669.
- Von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vanderbrouche JP, STROBE Initiative Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335:806–808. doi: 10.1136/.
- WHO (2020) Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected: interim guidance, 25 January 2020. Published January 25. . Accessed 15 Apr 2020.
- Brock GN, Barnes C, Ramirez JA, Myers J. How to handle mortality when investigating length of hospital stay and time to clinical stability. BMC Med Res Methodol. 2011;11:144. doi: 10.1186/1471-2288-11-144.
- Bellani G, Laffey JG, Pham T, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315:788–800. doi: 10.1001/jama.2016.0291.
- Kacmarek RM, Villar J, Sulemanji D, Open Lung Approach Network et al. Open lung approach for the acute respiratory distress syndrome: a pilot, randomized controlled trial. Crit Care Med. 2016;44:32–42. doi: 10.1097/CCM.0000000000001383.
- Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators. Cavalcanti AB, Suzumura ÉA, et al. Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA. 2017;318:1335–1345. doi: 10.1001/jama.2017.14171.
- Moss M, Ulysse CA, Angus DC, National Heart, lung and blood institute PETAL clinical trials network Early neuromuscular blockade in the acute respiratory distress syndrome. N Engl J Med. 2019;380:1997–2008. doi: 10.1056/NEJMc1908874.
- Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368:2159–2168. doi: 10.1056/NEJMoa1214103.
- Goyal P, Choi JJ, Pinheiro LC, et al. Clinical characteristics of COVID-19 in New York city. N Engl J Med. 2020;382:2372–2374. doi: 10.1056/NEJMc2010419.
- Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China. Lancet Respir Med. 2020;S2213–2600(20):30079–30085. doi: 10.1016/S2213-2600(20)30079-5.
- Villar J, Blanco J, Añón JM, et al. The ALIEN study: incidence and outcome of acute respiratory distress syndrome in the era of lung protective ventilation. Intensive Care Med. 2011;37:1932–1941. doi: 10.1007/s00134-011-2380-4.
- Madoto F, Pham T, Bellani G, et al. Resolved versus confirmed ARDS after 24h: insights from the LUNG SAFE study. Intensive Care Med. 2018;44:564–577. doi: 10.1007/s00134-018-5152-6.
- Villar J, Fernández RL, Ambrós A, et al. A clinical classification on the acute respiratory distress syndrome for predicting outcome and guiding medical therapy. Crit Care Med. 2015;43:346–353. doi: 10.1097/CCM.0000000000000703.
- Ziehr DR, Alladina J, Petri CR, et al. Respiratory pathophysiology of mechanically ventilated patients with COVID-19: a cohort study. Am J Respir Crit Care Med. 2020;201:1506–1564. doi: 10.1164/rccm.202004-1163LE.
- Schenck EJ, Hoffman K, Goyal P, et al. Respiratory mechanics and gas exchange in COVID-19 associated respiratory failure. Ann Am Thorac Soc. 2020 doi: 10.1513/AnnalsATS.202005-427RL.
- Bellani G, Pham T, Laffey J. Missed or delayed diagnosis of ARDS: a common and serious problem. Intensive Care Med. 2020;46:1180–1183. doi: 10.1007/s00134-020-06035-0.
- Pistillo N, Fariña O. Driving airway and transpulmonary pressure are correlated to VILI determinants during controlled ventilation. Intensive Care Med. 2018;44:674–675. doi: 10.1007/s00134-018-5092-1.
- Pensier J, de Jong A, Hajjej Z, et al. Effect of lung recruitment maneuver on oxygenation, physiological parameters and mortality in acute respiratory distress syndrome patients: a systematic review and meta-analysis. Intensive Care Med. 2019;45:1691–1702. doi: 10.1007/s00134-019-05821-9.
- Guérin C, Beuret P, Constantin JM, Investigators of the APRONET Study Group, the REVA Network, the Réseau recherche de la Société Française d’Anesthésie-Réanimation (SFAR-recherche) and the ESICM Trials Group et al. A prospective international observational prevalence study on prone positioning of ARDS patients: the APRONET (ARDS Prone Position Network) study. Intensive Care Med. 2018;44:22–37. doi: 10.1007/s00134-017-4996-5.
- Beloncle FM, Pavlovsky B, Desprez C, et al. Recruitability and effect of PEEP in SARS-Cov-2-associated acute respiratory distress syndrome. Ann Intensive Care. 2020;10:55. doi: 10.1186/s13613-020-00675-7.
- Spinelli E, Mauri T, Beitler J, et al. Respiratory drive in the acute respiratory distress syndrome: pathophysiology, monitoring, and therapeutic interventions. Intensive Care Med. 2020;46:606–618. doi: 10.1007/s00134-020-05942-6.
- Slutsky AS, Villar J. Early paralytic agents for ARDS? Yes, no, sometimes. N Engl J Med. 2019;380:2061–2063. doi: 10.1056/NEJMe1905627.
- Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497–506. doi: 10.1016/S0140-6736(20)30183-5.
- Arentz M, Yim E, Klaff L, et al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington State. JAMA. 2020;323:1612–1614. doi: 10.1001/jama.2020.4326.
Source: PubMed