Outcomes of COVID-19 patients treated with noninvasive respiratory support outside-ICU setting: a Portuguese reality (original) (raw)
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JAMA
IMPORTANCE Continuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) have been recommended for acute hypoxemic respiratory failure in patients with COVID-19. Uncertainty exists regarding the effectiveness and safety of these noninvasive respiratory strategies. OBJECTIVE To determine whether either CPAP or HFNO, compared with conventional oxygen therapy, improves clinical outcomes in hospitalized patients with COVID-19-related acute hypoxemic respiratory failure. DESIGN, SETTING, AND PARTICIPANTS A parallel group, adaptive, randomized clinical trial of 1273 hospitalized adults with COVID-19-related acute hypoxemic respiratory failure. The trial was conducted between April 6, 2020, and May 3, 2021, across 48 acute care hospitals in the UK and Jersey. Final follow-up occurred on June 20, 2021. INTERVENTIONS Adult patients were randomized to receive CPAP (n = 380), HFNO (n = 418), or conventional oxygen therapy (n = 475). MAIN OUTCOMES AND MEASURES The primary outcome was a composite of tracheal intubation or mortality within 30 days. RESULTS The trial was stopped prematurely due to declining COVID-19 case numbers in the UK and the end of the funded recruitment period. Of the 1273 randomized patients (mean age, 57.4 [95% CI, 56.7 to 58.1] years; 66% male; 65% White race), primary outcome data were available for 1260. Crossover between interventions occurred in 17.1% of participants (15.3% in the CPAP group, 11.5% in the HFNO group, and 23.6% in the conventional oxygen therapy group). The requirement for tracheal intubation or mortality within 30 days was significantly lower with CPAP (36.3%; 137 of 377 participants) vs conventional oxygen therapy (44.4%; 158 of 356 participants) (absolute difference, −8% [95% CI, −15% to −1%], P = .03), but was not significantly different with HFNO (44.3%; 184 of 415 participants) vs conventional oxygen therapy (45.1%; 166 of 368 participants) (absolute difference, −1% [95% CI, −8% to 6%], P = .83). Adverse events occurred in 34.2% (130/380) of participants in the CPAP group, 20.6% (86/418) in the HFNO group, and 13.9% (66/475) in the conventional oxygen therapy group. CONCLUSIONS AND RELEVANCE Among patients with acute hypoxemic respiratory failure due to COVID-19, an initial strategy of CPAP significantly reduced the risk of tracheal intubation or mortality compared with conventional oxygen therapy, but there was no significant difference between an initial strategy of HFNO compared with conventional oxygen therapy. The study may have been underpowered for the comparison of HFNO vs conventional oxygen therapy, and early study termination and crossover among the groups should be considered when interpreting the findings.
Scientific Reports
The effectiveness of noninvasive respiratory support in severe COVID-19 patients is still controversial. We aimed to compare the outcome of patients with COVID-19 pneumonia and hypoxemic respiratory failure treated with high-flow oxygen administered via nasal cannula (HFNC), continuous positive airway pressure (CPAP) or noninvasive ventilation (NIV), initiated outside the intensive care unit (ICU) in 10 university hospitals in Catalonia, Spain. We recruited 367 consecutive patients aged ≥ 18 years who were treated with HFNC (155, 42.2%), CPAP (133, 36.2%) or NIV (79, 21.5%). The main outcome was intubation or death at 28 days after respiratory support initiation. After adjusting for relevant covariates and taking patients treated with HFNC as reference, treatment with NIV showed a higher risk of intubation or death (hazard ratio 2.01; 95% confidence interval 1.32–3.08), while treatment with CPAP did not show differences (0.97; 0.63–1.50). In the context of the pandemic and outside t...
Noninvasive Ventilation in Severe Hypoxemic Respiratory Failure
American Journal of Respiratory and Critical Care Medicine, 2003
The efficacy of non-invasive ventilation in order to avoid intubation and improve survival was assessed in 105 patients with severe acute hypoxemic respiratory failure (arterial O 2 tension or saturation persistently ≤60 mmHg or ≤90%, respectively, breathing conventional Venturi oxygen at maximal concentration (50%)), excluding hypercapnia, admitted into intensive care units of 3 hospitals. Patients were randomly allocated within 24 hours of fulfilling inclusion criteria to receive non-invasive ventilation (n=51), or high concentration oxygen therapy (n=54). The primary end-point variable was the decrease in the intubation rate. Both groups had similar characteristics. Compared with oxygen therapy, non-invasive ventilation decreased the need for intubation (13, 25% vs 28, 52%, p=0.010), the incidence of septic shock (6, 12% vs 17, 31%, p=0.028), and the intensive care unit mortality (9, 18% vs 21, 39%, p=0.028), and increased the cumulative 90-day survival (p=0.025). The improvement of arterial hypoxemia and tachypnea was higher in the non-invasive-ventilation group with time (p=0.029 each).
Noninvasive Ventilation in Severe Hypoxemic Respiratory Failure A Randomized Clinical Trial
The efficacy of non-invasive ventilation in order to avoid intubation and improve survival was assessed in 105 patients with severe acute hypoxemic respiratory failure (arterial O 2 tension or saturation persistently ≤60 mmHg or ≤90%, respectively, breathing conventional Venturi oxygen at maximal concentration (50%)), excluding hypercapnia, admitted into intensive care units of 3 hospitals. Patients were randomly allocated within 24 hours of fulfilling inclusion criteria to receive non-invasive ventilation (n=51), or high concentration oxygen therapy (n=54). The primary end-point variable was the decrease in the intubation rate. Both groups had similar characteristics. Compared with oxygen therapy, non-invasive ventilation decreased the need for intubation (13, 25% vs 28, 52%, p=0.010), the incidence of septic shock (6, 12% vs 17, 31%, p=0.028), and the intensive care unit mortality (9, 18% vs 21, 39%, p=0.028), and increased the cumulative 90-day survival (p=0.025). The improvement of arterial hypoxemia and tachypnea was higher in the non-invasive-ventilation group with time (p=0.029 each).
ISCCM Guidelines for the Use of Non-invasive Ventilation in Acute Respiratory Failure in Adult ICUs
Indian Journal of Critical Care Medicine
A. ACUTE HYPERCAPNIC RESPIRATORY FAILURE A1. Acute Exacerbation of COPD: Recommendations: NIV should be used in management of acute exacerbation of COPD in patients with acute or acute-on-chronic respiratory acidosis (pH = 7.25-7.35). (1A) NIV should be attempted in patients with acute exacerbation of COPD (pH <7.25 & PaCO2 ≥ 45) before initiating invasive mechanical ventilation (IMV) except in patients requiring immediate intubation. (2A). Lower the pH higher the chance of failure of NIV. (2B) NIV should not to be used routinely in normo-or mildly hyper-capneic patients with acute exacerbation of COPD, without acidosis (pH > 7.35). (2B) A2. NIV in ARF due to Chest wall deformities/ Neuromuscular diseases: Recommendations: NIV may be used in patients of ARF due to chest wall deformity/Neuromuscular diseases. (PaCO2 ≥ 45) (UPP) A3. NIV in ARF due to Obesity hypoventilation syndrome (OHS): Recommendations: NIV may be used in AHRF in OHS patients when they present with acute hypercapnic or acute on chronic respiratory failure (pH 45). (3B) NIV/CPAP may be used in obese, hypercapnic patients with OHS and/or right heart failure in the absence of acidosis. (UPP) B. NIV IN ACUTE HYPOXEMIC RESPIRATORY FAILURE: B1. NIV in Acute Cardiogenic Pulmonary Oedema: Recommendations: NIV is recommended in hospital patients with ARF, due to Cardiogenic pulmonary edema. (1A). NIV should be used in patients with acute heart failure/ cardiogenic pulmonary edema, right from emergency department itself. (1B) Both CPAP and BiPAP modes are safe and effective in patients with cardiogenic pulmonary edema. (1A). However, BPAP (NIV-PS) should be preferred in cardiogenic pulmonary edema with hypercapnia. (3A) B2. NIV in acute hypoxemic respiratory failure: Recommendations: NIV may be used over conventional oxygen therapy in mild early acute hypoxemic respiratory failure (P/F ratio <300 and >200 mmHg), under close supervision. (2B) We strongly recommend against a trial of NIV in patients with acute hypoxemic failure with P/F ratio <150. (2A) B3. NIV in ARF due to Chest Trauma: Recommendations: NIV may be used in traumatic flail chest along with adequate pain relief. (3B) B4. NIV in Immunocompromised Host: Recommendations: In Immunocompromised patients with early ARF, we may consider NIV over conventional oxygen. (2B). B5. NIV in Palliative Care: Recommendations: We strongly recommend use of NIV for reducing dyspnea in palliative care setting. (2A) B6. NIV in post-operative cases: Recommendations: NIV should be used in patients with post-operative acute respiratory failure. (2A) B6a. NIV in abdominal surgery: Recommendations: NIV may be used in patients with ARF following abdominal surgeries. (2A) B6b. NIV in bariatric surgery: Recommendations: NIV may be used in post-bariatric surgery patients with pre-existent OSA or OHS. (3A) B6c. NIV in Thoracic surgery: Recommendations: In cardiothoracic surgeries, use of NIV is recommended post operatively for acute respiratory failure to improve oxygenation and reduce chance of reintubation. (2A) NIV should not be used in patients undergoing esophageal surgery. (UPP) B6d. NIV in post lung transplant: Recommendations: NIV may be used for shortening weaning time and to avoid re-intubation following lung transplantation. (2B) B7. NIV during Procedures (ETI/Bronchoscopy/TEE/Endoscopy): Recommendations: NIV may be used for pre-oxygenation before intubation. (2B) NIV with appropriate interface may be used in patients of ARF during Bronchoscopy/Endoscopy to improve oxygenation. (3B) B8. NIV in Viral Pneumonitis ARDS: Recommendations: NIV cannot be considered as a treatment of choice for patients with acute respiratory failure with H1N1 pneumonia. However, it may be reasonable to use NIV in selected patients with single organ involvement, in a strictly controlled environment with close monitoring. (2B) B9. NIV and Acute exacerbation of Pulmonary Tuberculosis: Recommendations: Careful use of NIV in patients with acute Tuberculosis may be considered, with effective infection control precautions to prevent airborne transmission. (3B) B10. NIV after planned extubation in high risk patients: Recommendation: We recommend that NIV may be used to wean high risk patients from invasive mechanical ventilation as it reduces re-intubation rate. (2B) B11. NIV for respiratory distress post extubation: Recommendations: We recommend that NIV therapy should not be used to manage respiratory distress post-extubation in high risk patients. (2B) C. APPLICATION OF NIV: Recommendation: Choice of mode should be mainly decided by factors like disease etiology and severity, the breathing effort by the patient and the operator familiarity and experience. (UPP) We suggest using flow trigger over pressure triggering in assisted modes, as it provides better patient ventilator synchrony. Especially in COPD patients, flow triggering has been found to benefit auto PEEP. (3B) D. MANAGEMENT OF PATIENT ON NIV: D1. Sedation: Recommendations: A non-pharmacological approach to calm the patient (Reassuring the patient, proper environment) should always be tried before administrating sedatives. (UPP) In patients on NIV, sedation may be used with extremely close monitoring and only in an ICU setting with lookout for signs of NIV failure. (UPP) E. EQUIPMENT: Recommendations: We recommend that portable bilevel ventilators or specifically designed ICU ventilators with non-invasive mode should be used for delivering Non-invasive ventilation in critically ill patients. (UPP) Both critical care ventilators with leak compensation and bi-level ventilators have been equally effective in decreasing the WOB, RR, and PaCO2. (3B) Currently, Oronasal mask is the most preferred interface for non-invasive ventilation for acute respiratory failure. (3B) F. WEANING: Recommendations: We recommend that weaning from NIV may be done by a standardized protocol driven approach of the unit. (2B)
A Survey of Noninvasive Ventilation Practices in a Respiratory ICU of North India
Respiratory Care, 2012
BACKGROUND: There is paucity of data from India on the use of noninvasive ventilation (NIV) in acute respiratory failure (ARF). In this observational study, we report the indications and outcomes of patients requiring NIV in the respiratory ICU of a tertiary care hospital. METHODS: All patients with ARF requiring NIV were included in the study. NIV was delivered through critical care ventilators, using oronasal mask. The disease severity and new-onset organ dysfunction/failure were calculated using the Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, respectively. A multivariate logistic regression model was used to analyze the factors predicting NIV failure. RESULTS: There were 92 subjects (48 men, 44 women, mean ؎ SD age 48 ؎ 17.5 y) who received 101 NIV applications (42 and 59 applications for episodes of hypoxemic and hypercapnic ARF, respectively) during the study period. The most common causes of hypoxemic and hypercapnic respiratory failure were acute lung injury/ARDS (29%) and COPD (29%), respectively. There was significant improvement in heart rate and respiratory rate after 1, 2, and 4 hours, compared to the baseline, in both the groups. Of the NIV applications, 53.5% required endotracheal intubation, with the number being significantly higher in hypoxemic (67%), compared to hypercapnic (44%), ARF (P ؍ .03). The P aO 2 /F IO 2 measured after 1 hour of NIV application had significant impact on outcome in patients with hypoxemic but not hypercapnic ARF. A P aO 2 /F IO 2 of < 146 mm Hg at one hour had a better specificity (85.7% vs 71.4%), versus a P aO 2 /F IO 2 of < 175 mm Hg in predicting NIV failure in patients with hypoxemic ARF. On multivariate logistic regression analysis, baseline APACHE II score, ⌬SOFA score, hypoxemic respiratory failure, and change in P aO 2 /F IO 2 at 1 hour from baseline were associated with NIV failure. CONCLUSIONS: NIV was found to be a useful modality in management of patients with hypercapnic versus hypoxemic respiratory failure. The severity of illness at admission, newonset organ dysfunction, hypoxemic ARF, and delay in improvement in P aO 2 /F IO 2 at 1 hour from baseline are independent predictors of NIV failure.
Effectiveness of noninvasive ventilation in COVID‐19 related‐acute respiratory distress syndrome
The Clinical Respiratory Journal, 2021
Introduction: During this long COVID-19 pandemic outbreak, continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) are being widely used to treat patients with moderate to severe acute respiratory failure (ARF). As for now, data on the efficacy of NIV in COVID-19 acute respiratory distress syndrome (ARDS) are lacking, and for this reason it is extremely important to accurately determine the outcomes of this strategy. This study aimed to evaluate clinical data and outcomes of NIV in patients with COVID-19 ARDS. Matherials and methods: Seventy-nine consecutive patients with sudden worsening of respiratory failure were evaluated. All patients (71% male) had a confirmed SARS-CoV-2 infection and signs, symptoms and radiological findings compatible with COVID-19 pneumonia and all of them underwent a trial of NIV. Primary outcomes were NIV success and failure defined by intubation and mortality rate. Secondary outcome was the duration of NIV. Results: NIV was successful in 38 (48.1%) patients (Table 1). EOT was necessary in 21 patients (26.6%). Death occurred in 20 patients (25.3%). In the group of patients having failed a trial with NIV and then being intubated, compared to those who continued NIV, there was no higher mortality rate. By evaluating the ICU survival outcome of the subgroup of patients intubated after NIV, 57% of the patients were discharged and 43% died. Conclusion: Previous studies conducted on patients undergoing invasive mechanical ventilation showed higher mortality rate than the present study. Our data showed that NIV can avoid intubation in almost half of the patients. Therefore, this data could reassure clinicians who would consider using NIV in COVID-19 ARDS-related treatment.
Research Square (Research Square), 2021
Introduction The e cacy of non-invasive ventilation (NIV) in acute respiratory failure secondary to SARS-CoV-2 infection remains controversial. Current literature mainly examined e cacy, safety and potential predictors of NIV failure provided out of the Intensive Care Unit (ICU). On the contrary, the outcomes of ICU patients, intubated after NIV failure, remain to be explored. The aims of the present study are: 1) investigating in-hospital mortality in coronavirus disease 2019 (COVID-19) ICU patients receiving endotracheal intubation after NIV failure and 2) assessing whether the length of NIV application affects patient survival. Methods This observational multicenter study included all consecutive COVID-19 adult patients, admitted into the twenty-ve ICUs of the COVID-19 VENETO ICU network (February-April 2020), who underwent endotracheal intubation after NIV failure. Results Among the 704 patients admitted to ICU during the study period, 280 (40%) presented the inclusion criteria and were enrolled. The median age was 69 [60-76] years; 219 patients (78%) were male. Inhospital mortality was 43%. Only the length of NIV application before ICU admission (OR 2.03 (95% CI 1.06-4.98), p = 0.03) and age (OR 1.18 (95% CI 1.04-1.33), p < 0.01) were identi ed as independent risk factors of in-hospital mortality; whilst the length of NIV after ICU admission did not affect patient outcome. Conclusions In-hospital mortality of ICU patients intubated after NIV failure was 43%. Days on NIV before ICU admission and age were assessed to be potential risk factors of greater in-hospital mortality.
Annals of Intensive Care, 2020
Objective Critically ill patients admitted in ICU because of COVID-19 infection display severe hypoxemic respiratory failure. The Surviving Sepsis Campaign recommends oxygenation through high-flow nasal cannula over non-invasive ventilation. The primary outcome of our study was to evaluate the effect of the addition of a surgical mask on a high-flow nasal cannula system on oxygenation parameters in hypoxemic COVID-19 patients admitted in ICU who do not require urgent intubation. The secondary outcomes were relevant changes in PaCO2 associated with clinical modifications and patient’s feelings. Design We prospectively assessed 21 patients admitted in our mixed Intensive Care Unit of the Cliniques Universitaires Saint Luc. Main results While FiO2 was unchanged, we demonstrate a significant increase of PaO2 (from 59 (± 6), to 79 mmHg (± 16), p < 0.001), PaO2/FiO2 from 83 (± 22), to 111 (± 38), p < 0.001) and SaO2 (from 91% (± 1.5), to 94% (± 1.6), p < 0.001), while the patient...