The impact of mechanical ventilation parameters and management on outcomes of patients with coronavirus disease 2019 (COVID-19) ARDS is unclear.
METHODS:
This multi-center observational study enrolled consecutive mechanically ventilated patients with COVID-19 ARDS admitted to one of 7 Korean ICUs between February 1, 2020–February 28, 2021. Patients who were age < 17 y or had missing ventilation parameters for the first 4 d of mechanical ventilation were excluded. Multivariate logistic regression was used to identify which strategies or ventilation parameters that were independently associated with ICU mortality.
RESULTS:
Overall, 129 subjects (males, 60%) with a median (interquartile range) age of 69 (62–78) y were included. Neuromuscular blocker (NMB) use and prone positioning were applied to 76% and 16% of subjects, respectively. The ICU mortality rate was 37%. In the multivariate analysis, higher dynamic driving pressure (ΔP) values during the first 4 d of mechanical ventilation were associated with increased mortality (adjusted odds ratio 1.16 [95% CI 1.00–1.33], P = .046). NMB use was associated with decreased mortality (adjusted odds ratio 0.27 [95% CI 0.09–0.81], P = .02). The median tidal volume values during the first 4 d of mechanical ventilation and the ICU mortality rate were significantly lower in the NMB group than in the no NMB group. However, subjects who received NMB for ≥ 6 d (vs < 6 d) had higher ICU mortality rate.
CONCLUSIONS:
In subjects with COVID-19 ARDS receiving mechanical ventilation, ΔP during the first 4 d of mechanical ventilation was independently associated with mortality. The short-term use of NMB facilitated lung-protective ventilation and was independently associated with decreased mortality.
GuanWJ, NiZY, HuY, LiangWH, OuCQ, HeJX, et al. China Medical Treatment Expert Group for COVID-19. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med, 2020; 382(18):1708-1720.
2.
GrasselliG, ZangrilloA, ZanellaA, AntonelliM, CabriniL, CastelliA, et al. COVID-19 Lombardy ICU Network. Baseline characteristics and outcomes of 1,591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region, Italy. JAMA, 2020; 323(16):1574-1581.
MitraAR, FergussonNA, Lloyd-SmithE, WormsbeckerA, FosterD, KarpovA, et al. Baseline characteristics and outcomes of patients with COVID-19 admitted to intensive care units in Vancouver, Canada: a case series. CMAJ, 2020; 192(26):E694-E701.
5.
Namendys-SilvaSA, Gutierrez-VillasenorA, Romero-GonzalezJP. Hospital mortality in mechanically ventilated COVID-19 patients in Mexico. Intensive Care Med, 2020; 46(11):2086-2088.
6.
GattinoniL, CoppolaS, CressoniM, BusanaM, RossiS, ChiumelloD. COVID-19 does not lead to a “typical” acute respiratory distress syndrome. Am J Respir Crit Care Med, 2020; 201(10):1299-1300.
7.
ChiumelloD, BusanaM, CoppolaS, RomittiF, FormentiP, BonifaziM, et al. Physiological and quantitative CT-scan characterization of COVID-19 and typical ARDS: a matched cohort study. Intensive Care Med, 2020; 46(12):2187-2196.
8.
GrasselliG, CattaneoE, FlorioG, IppolitoM, ZanellaA, CortegianiA, et al. Mechanical ventilation parameters in critically ill COVID-19 patients: a scoping review. Crit Care, 2021; 25(1):115.
9.
National Heart, Lung, and Blood Institute, PETAL Clinical Trials Network;. MossM, HuangDT, BrowerRG, FergusonND, et al. Early neuromuscular blockade in the acute respiratory distress syndrome. N Engl J Med, 2019; 380(21):1997-2008.
10.
GuerinC, ReignierJ, RichardJC, BeuretP, GacouinA, BoulainT, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med, 2013; 368(23):2159-2168.
11.
AlhazzaniW, MollerMH, ArabiYM, LoebM, GongMN, FanE, et al. Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Crit Care Med, 2020; 48(6):e440-e469.
12.
VincentJL, MorenoR, TakalaJ, WillattsS, De MendoncaA, BruiningH, et al. The SOFA (sepsis-related organ failure assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med, 1996; 22(7):707-710.
13.
CormanVM, LandtO, KaiserM, MolenkampR, MeijerA, ChuDK, et al. Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR. Euro Surveill, 2020; 25(3):2000045.
14.
ARDS Definition Task Force;. RanieriVM, RubenfeldGD, ThompsonBT, FergusonND, CaldwellE, FanE, et al. Acute respiratory distress syndrome: the Berlin definition. JAMA, 2012; 307(23):2526-2533.
15.
ChiuLC, HuHC, HungCY, ChangCH, TsaiFC, YangCT, et al. Dynamic driving pressure-associated mortality in acute respiratory distress syndrome with extracorporeal membrane oxygenation. Ann Intensive Care, 2017; 7(1):12.
16.
GattinoniL, TonettiT, CressoniM, CadringherP, HerrmannP, MoererO, et al. Ventilator-related causes of lung injury: the mechanical power. Intensive Care Med, 2016; 42(10):1567-1575.
17.
SinhaP, CalfeeCS, BeitlerJR, SoniN, HoK, MatthayMA, et al. Physiologic analysis and clinical performance of the ventilatory ratio in acute respiratory distress syndrome. Am J Respir Crit Care Med, 2019; 199(3):333-341.
18.
AmatoMB, MeadeMO, SlutskyAS, BrochardL, CostaEL, SchoenfeldDA, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med, 2015; 372(8):747-755.
19.
Serpa NetoA, SchmidtM, AzevedoLC, BeinT, BrochardL, BeutelG, et al. ReVA Research Network and the PROVE Network Investigators. Associations between ventilator settings during extracorporeal membrane oxygenation for refractory hypoxemia and outcome in patients with acute respiratory distress syndrome: a pooled individual patient data analysis: mechanical ventilation during ECMO. Intensive Care Med, 2016; 42(11):1672-1684.
20.
Li BassiG, SuenJY, DaltonHJ, WhiteN, ShrapnelS, FanningJP, et al. COVID-19 Critical Care Consortium. An appraisal of respiratory system compliance in mechanically ventilated COVID-19 patients. Crit Care, 2021; 25(1):199.
21.
RECOVERY Collaborative Group;. HorbyP, LimWS, EmbersonJR, MafhamM, BellJL, et al. Dexamethasone in hospitalized patients with COVID-19. N Engl J Med, 2021; 384(8):693-704.
22.
COVID-ICU Group on behalf of the REVA Network and the COVID-ICU Investigators. Clinical characteristics and day-90 outcomes of 4244 critically ill adults with COVID-19: a prospective cohort study. Intensive Care Med, 2021; 47(1):60-73.
23.
BellaniG, LaffeyJG, PhamT, FanE, BrochardL, EstebanA, et al. ESICM Trials Group. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA, 2016; 315(8):788-800.
24.
Serpa NetoA, DeliberatoRO, JohnsonAEW, BosLD, AmorimP, PereiraSM, et al. PROVE Network Investigators. Mechanical power of ventilation is associated with mortality in critically ill patients: an analysis of patients in two observational cohorts. Intensive Care Med, 2018; 44(11):1914-1922.
25.
HaudebourgAF, PerierF, TuffetS, de ProstN, RazaziK, Mekontso DessapA, et al. Respiratory mechanics of COVID-19- versus non-COVID-19-associated acute respiratory distress syndrome. Am J Respir Crit Care Med, 2020; 202(2):287-290.
26.
BeloncleFM, PavlovskyB, DesprezC, FageN, OlivierPY, AsfarP, et al. Recruitability and effect of PEEP in SARS-Cov-2-associated acute respiratory distress syndrome. Ann Intensive Care, 2020; 10(1):55.
27.
RoesthuisL, van den BergM, van der HoevenH. Advanced respiratory monitoring in COVID-19 patients: use less PEEP!.Crit Care, 2020; 24(1):230.
28.
MariniJJ, GattinoniL. Management of COVID-19 respiratory distress. JAMA, 2020; 323(22):2329-2330.
29.
FerrandoC, Suarez-SipmannF, Mellado-ArtigasR, HernandezM, GeaA, ArrutiE, et al. COVID-19 Spanish ICU Network. Clinical features, ventilatory management, and outcome of ARDS caused by COVID-19 are similar to other causes of ARDS. Intensive Care Med, 2020; 46(12):2200-2211.
30.
VandenbunderB, EhrmannS, PiagnerelliM, SauneufB, SerckN, SoumagneT, et al. COVADIS study group. Static compliance of the respiratory system in COVID-19 related ARDS: an international multicenter study. Crit Care, 2021; 25(1):52.
31.
FusinaF, AlbaniF, BertelliM, CavalloE, CrisciS, CasertaR, et al. Corrected minute ventilation is associated with mortality in ARDS caused by COVID-19. Respir Care, 2021; 66(4):619-625.
32.
Morales-QuinterosL, NetoAS, ArtigasA, BlanchL, BottaM, KaufmanDA, et al. PRoVENT-COVID Study Group. Dead space estimates may not be independently associated with 28-day mortality in COVID-19 ARDS. Crit Care, 2021; 25(1):171.
33.
RenewJR, RatzlaffR, Hernandez-TorresV, BrullSJ, PrielippRC. Neuromuscular blockade management in the critically Ill patient. J Intensive Care, 2020; 8:37.
34.
CourcelleR, GaudryS, SerckN, BlonzG, LascarrouJB, GrimaldiD. on behalf the COVADIS study group. Neuromuscular blocking agents (NMBA) for COVID-19 acute respiratory distress syndrome: a multi-center observational study. Crit Care, 2020; 24(1):446.
35.
SpinelliE, MauriT, BeitlerJR, PesentiA, BrodieD. Respiratory drive in the acute respiratory distress syndrome: pathophysiology, monitoring, and therapeutic interventions. Intensive Care Med, 2020; 46(4):606-618.
36.
GeH, PanQ, ZhouY, XuP, ZhangL, ZhangJ, et al. Lung mechanics of mechanically ventilated patients with COVID-19: analytics with high-granularity ventilator waveform data. Front Med (Lausanne), 2020; 7(541).
37.
KarayiannisD, MaragkoutiA, MikropoulosT, SarriA, KanavouA, KatsagoniC, et al. Neuromuscular blockade administration is associated with altered energy expenditure in critically ill intubated patients with COVID-19. Clin Nutr, 2021[Epub ahead of print]. doi: 10.1016/j.clnu.2021.05.009.
38.
PapazianL, ForelJM, GacouinA, Penot-RagonC, PerrinG, LoundouA, et al. ACURASYS Study Investigators. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med, 2010; 363(12):1107-1116.
39.
KimEJ, LeeYH, ParkJS, LeeJ, LeeSY, KimY, et al. Clinical features and prognostic factors of critically ill patients with COVID-19 in Daegu, South Korea: A multi-center retrospective study. Medicine (Baltimore), 2021; 100(7):e24437.
40.
MathewsKS, SohH, ShaefiS, WangW, BoseS, CocaS, et al. STOP-COVID Investigators. Prone positioning and survival in mechanically ventilated patients with coronavirus disease 2019-related respiratory failure. Crit Care Med, 2021; 49(7):1026-1037.
41.
SchmidtM, StewartC, BaileyM, NieszkowskaA, KellyJ, MurphyL, et al. Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: a retrospective international multicenter study. Crit Care Med, 2015; 43(3):654-664.
