Respiratory support in patients with severe COVID-19 in the International Severe Acute Respiratory and Emerging Infection (ISARIC) COVID-19 study: a prospective, multinational, observational study
Luis Felipe Reyes, Srinivas Murthy, Esteban García-Gallo, Laura Merson, Elsa D. Ibáñez-Prada, Jordi Rello, Yuli V. Fuentes, Ignacio Martín‐Loeches, Fernando A. Bozza, Sara Duque, Fabio Silvio Taccone, Robert Fowler, Christiana Kartsonaki, Bronner P. Gonçalves, Barbara Wanjiru Citarella, Diptesh Aryal, Erlina Burhan, Matthew J. Cummings, Christelle Delmas, Rodrigo Díaz, Claudia Figueiredo-Mello, Madiha Hashmi, Prasan Kumar Panda, Miguel Pedrera‐Jiménez, Diego Fernando Bautista Rincón, David Thomson, Alistair Nichol, John C. Marshall, Piero Olliaro, the ISARIC Characterization Group, Ali Abbas, Sheryl Ann Abdukahil, Ryuzo Abe, Laurent Abel, Lara Absil, Subhash Acharya, Andrew Acker, Diana Adrião, Saleh Al Ageel, Shakeel Ahmed, Kate Ainscough, Tharwat Aisa, Ali Ait Hssain, Younes Ait Tamlihat, Takako Akimoto, Ernita Akmal, Eman Al Qasim, Razi Alalqam, Tala Al-dabbous, Senthilkumar Alegesan, Cynthia Alegre, Marta Alessi, Beatrice Alex, Kévin Alexandre, Abdulrahman Al‐Fares, Huda Alfoudri, Imran Ali, Naseem Ali Shah, Kazali Enagnon Alidjnou, Jeffrey Aliudin, Qabas Alkhafajee, Clotilde Allavena, Nathalie Allou, Aneela Altaf, João Alves, João Melo Alves, Rita Vieira Alves, Joana Alves Cabrita, Maria João Amaral, Phoebe Ampaw, Roberto Andini, Claire Andréjak, Andrea Angheben, François Angoulvant, Séverine Ansart, Massimo Antonelli, Carlos Alexandre Antunes de Brito, Ardiyan Apriyana, Yaseen M. Arabi, Irene Aragão, Carolline Araujo, Antonio Arcadipane, Patrick Archambault, Lukas Arenz, Jean‐Benoît Arlet, Christel Arnold-Day, Lovkesh Arora, Rakesh C. Arora, Élise Artaud-Macari, Diptesh Aryal, Ángel Asensio, Namra Asif, Mohammad Asim, Jean‐Baptiste Assié, Anika Atique, A. M. Udara Lakshan Attanyake, Johann Auchabie, Hugues Aumaître, Adrien Auvet, Laurène Azemar
Abstract
BACKGROUND: Up to 30% of hospitalised patients with COVID-19 require advanced respiratory support, including high-flow nasal cannulas (HFNC), non-invasive mechanical ventilation (NIV), or invasive mechanical ventilation (IMV). We aimed to describe the clinical characteristics, outcomes and risk factors for failing non-invasive respiratory support in patients treated with severe COVID-19 during the first two years of the pandemic in high-income countries (HICs) and low middle-income countries (LMICs). METHODS: This is a multinational, multicentre, prospective cohort study embedded in the ISARIC-WHO COVID-19 Clinical Characterisation Protocol. Patients with laboratory-confirmed SARS-CoV-2 infection who required hospital admission were recruited prospectively. Patients treated with HFNC, NIV, or IMV within the first 24 h of hospital admission were included in this study. Descriptive statistics, random forest, and logistic regression analyses were used to describe clinical characteristics and compare clinical outcomes among patients treated with the different types of advanced respiratory support. RESULTS: A total of 66,565 patients were included in this study. Overall, 82.6% of patients were treated in HIC, and 40.6% were admitted to the hospital during the first pandemic wave. During the first 24 h after hospital admission, patients in HICs were more frequently treated with HFNC (48.0%), followed by NIV (38.6%) and IMV (13.4%). In contrast, patients admitted in lower- and middle-income countries (LMICs) were less frequently treated with HFNC (16.1%) and the majority received IMV (59.1%). The failure rate of non-invasive respiratory support (i.e. HFNC or NIV) was 15.5%, of which 71.2% were from HIC and 28.8% from LMIC. The variables most strongly associated with non-invasive ventilation failure, defined as progression to IMV, were high leukocyte counts at hospital admission (OR [95%CI]; 5.86 [4.83-7.10]), treatment in an LMIC (OR [95%CI]; 2.04 [1.97-2.11]), and tachypnoea at hospital admission (OR [95%CI]; 1.16 [1.14-1.18]). Patients who failed HFNC/NIV had a higher 28-day fatality ratio (OR [95%CI]; 1.27 [1.25-1.30]). CONCLUSIONS: In the present international cohort, the most frequently used advanced respiratory support was the HFNC. However, IMV was used more often in LMIC. Higher leucocyte count, tachypnoea, and treatment in LMIC were risk factors for HFNC/NIV failure. HFNC/NIV failure was related to worse clinical outcomes, such as 28-day mortality. Trial registration This is a prospective observational study; therefore, no health care interventions were applied to participants, and trial registration is not applicable.