Association Between Early Invasive Mechanical Ventilation and Day-60 Mortality in Acute Hypoxemic Respiratory Failure Related to Coronavirus Disease-2019 Pneumonia

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Abstract

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Abstract

Objectives:

About 5% of patients with coronavirus disease-2019 are admitted to the ICU for acute hypoxemic respiratory failure. Opinions differ on whether invasive mechanical ventilation should be used as first-line therapy over noninvasive oxygen support. The aim of the study was to assess the effect of early invasive mechanical ventilation in coronavirus disease-2019 with acute hypoxemic respiratory failure on day-60 mortality.

Design:

Multicenter prospective French observational study.

Setting:

Eleven ICUs of the French OutcomeRea network.

Patients:

Coronavirus disease-2019 patients with acute hypoxemic respiratory failure (Pa o ₂/F io ₂ ≤ 300 mm Hg), without shock or neurologic failure on ICU admission, and not referred from another ICU or intermediate care unit were included.

Intervention:

We compared day-60 mortality in patients who were on invasive mechanical ventilation within the first 2 calendar days of the ICU stay (early invasive mechanical ventilation group) and those who were not (nonearly invasive mechanical ventilation group). We used a Cox proportional-hazard model weighted by inverse probability of early invasive mechanical ventilation to determine the risk of death at day 60.

Measurement and Main Results:

The 245 patients included had a median (interquartile range) age of 61 years (52–69 yr), a Simplified Acute Physiology Score II score of 34 mm Hg (26–44 mm Hg), and a Pa o ₂/F io ₂ of 121 mm Hg (90–174 mm Hg). The rates of ICU-acquired pneumonia, bacteremia, and the ICU length of stay were significantly higher in the early ( n = 117 [48%]) than in the nonearly invasive mechanical ventilation group ( n = 128 [52%]), p < 0.01. Day-60 mortality was 42.7% and 21.9% in the early and nonearly invasive mechanical ventilation groups, respectively. The weighted model showed that early invasive mechanical ventilation increased the risk for day-60 mortality (weighted hazard ratio =1.74; 95% CI, 1.07–2.83, p=0.03).

Conclusions:

In ICU patients admitted with coronavirus disease-2019-induced acute hypoxemic respiratory failure, early invasive mechanical ventilation was associated with an increased risk of day-60 mortality. This result needs to be confirmed.

Related collections

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The acute respiratory distress syndrome (ARDS) was defined in 1994 by the American-European Consensus Conference (AECC); since then, issues regarding the reliability and validity of this definition have emerged. Using a consensus process, a panel of experts convened in 2011 (an initiative of the European Society of Intensive Care Medicine endorsed by the American Thoracic Society and the Society of Critical Care Medicine) developed the Berlin Definition, focusing on feasibility, reliability, validity, and objective evaluation of its performance. A draft definition proposed 3 mutually exclusive categories of ARDS based on degree of hypoxemia: mild (200 mm Hg < PaO2/FIO2 ≤ 300 mm Hg), moderate (100 mm Hg < PaO2/FIO2 ≤ 200 mm Hg), and severe (PaO2/FIO2 ≤ 100 mm Hg) and 4 ancillary variables for severe ARDS: radiographic severity, respiratory system compliance (≤40 mL/cm H2O), positive end-expiratory pressure (≥10 cm H2O), and corrected expired volume per minute (≥10 L/min). The draft Berlin Definition was empirically evaluated using patient-level meta-analysis of 4188 patients with ARDS from 4 multicenter clinical data sets and 269 patients with ARDS from 3 single-center data sets containing physiologic information. The 4 ancillary variables did not contribute to the predictive validity of severe ARDS for mortality and were removed from the definition. Using the Berlin Definition, stages of mild, moderate, and severe ARDS were associated with increased mortality (27%; 95% CI, 24%-30%; 32%; 95% CI, 29%-34%; and 45%; 95% CI, 42%-48%, respectively; P < .001) and increased median duration of mechanical ventilation in survivors (5 days; interquartile [IQR], 2-11; 7 days; IQR, 4-14; and 9 days; IQR, 5-17, respectively; P < .001). Compared with the AECC definition, the final Berlin Definition had better predictive validity for mortality, with an area under the receiver operating curve of 0.577 (95% CI, 0.561-0.593) vs 0.536 (95% CI, 0.520-0.553; P < .001). This updated and revised Berlin Definition for ARDS addresses a number of the limitations of the AECC definition. The approach of combining consensus discussions with empirical evaluation may serve as a model to create more accurate, evidence-based, critical illness syndrome definitions and to better inform clinical care, research, and health services planning.

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Author and article information

Journal

Journal ID (nlm-ta): Crit Care Explor

Journal ID (iso-abbrev): Crit Care Explor

Journal ID (publisher-id): CC9

Title: Critical Care Explorations

Publisher: Lippincott Williams & Wilkins (Hagerstown, MD )

ISSN (Electronic): 2639-8028

Publication date (Electronic): 22 January 2021

Publication date Collection: January 2021

Volume: 3

Issue: 1

Electronic Location Identifier: e0329

Affiliations

[1 ] Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France.

[2 ] Université de Paris, UMR 1137, IAME, Paris, France.

[3 ] AP-HP, Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard Hospital, Paris, France.

[4 ] Polyvalent ICU, Groupe Hospitalier Intercommunal Le Raincy Montfermeil, Montfermeil, France.

[5 ] Medical Intensive Care Unit, Grenoble University Hospital, La Tronche, France.

[6 ] Medical Intensive Care Unit, Nantes University Hospital, Nantes, France.

[7 ] Polyvalent ICU, Hôpital Foch, Suresnes, France.

[8 ] F-CRIN PARTNERS Platform, AP-HP, Université de Paris, Paris, France.

[9 ] Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, USPC, Université de Paris, Paris, France.

[10 ] Polyvalent ICU, Centre Hospitalier Sud Essonne Dourdan-Etampes, Étampes, France.

[11 ] Department of Biostatistics, ICUREsearch, Paris, France.

[12 ] AP-HP, Epidemiology, Hôpital Robert Debré, Paris, France.

[13 ] Medical Intensive Care Unit, Robert Debré University Hospital, Reims, France.

[14 ] University Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, Grenoble, France.

[15 ] Medical-Surgical Intensive Care Unit, André Mignot Hospital, Le Chesnay, France.

[16 ] AP-HM, Intensive Care Unit, La Timone University Hospital, Marseilles, France.

Author notes

For information regarding this article, E-mail: cdupuis1@ 123456chu-clermontferrand.fr

Article

Accession ID: 00024

DOI: 10.1097/CCE.0000000000000329

PMC ID: 7838010

PubMed ID: 33521646

SO-VID: 7a3d741a-32ed-45cc-8c78-0af22c73ef10

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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Keywords: acute hypoxemic respiratory failure,coronavirus disease 2019,critically ill,invasive mechanical ventilation,mortality,noninvasive oxygen support

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Keywords: acute hypoxemic respiratory failure, coronavirus disease 2019, critically ill, invasive mechanical ventilation, mortality, noninvasive oxygen support