Low PEEP Mechanical Ventilation and PaO2/FiO2 Ratio Evolution in COVID-19 Patients

  1. Samuele Ceruti
  2. Marco Roncador
  3. Andrea Saporito
  4. Maira Biggiogero
  5. Andrea Glotta
  6. Pier Andrea Maida
  7. Patrizia Urso
  8. Giovanni Bona
  9. Christian Garzoni
  10. Romano Mauri
  11. Alain Borgeat

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Abstract

Invasive mechanical ventilation (IMV) is the standard treatment in critically ill COVID-19 patients with acute severe respiratory distress syndrome (ARDS). When IMV setting is extremely aggressive, especially through the application of high positive-end-expiratory respiration (PEEP) values, lung damage can occur. Until today, in COVID-19 patients, two types of ARDS were identified (L- and H-type); for the L-type, a lower PEEP strategy was supposed to be preferred, but data are still missing. The aim of this study was to evaluate if a clinical management with lower PEEP values in critically ill L-type COVID-19 patients was safe and efficient in comparison to usual standard of care. A retrospective analysis was conducted on consecutive patients with COVID-19 ARDS admitted to the ICU and treated with IMV. Patients were treated with a lower PEEP strategy adapted to BMI: PEEP 10 cmH 2 O if BMI < 30 kg m −2 , PEEP 12 cmH 2 O if BMI 30–50 kg m −2 , PEEP 15 cmH 2 O if BMI > 50 kg m −2 . Primary endpoint was the PaO 2 /FiO 2 ratio evolution during the first 3 IMV days; secondary endpoints were to analyze ICU length of stay (LOS) and IMV length. From March 2 to January 15, 2021, 79 patients underwent IMV. Average applied PEEP was 11 ± 2.9 cmH 2 O for BMI < 30 kg m −2 and 16 ± 3.18 cmH 2 O for BMI > 30 kg m −2 . During the first 24 h of IMV, patients’ PaO 2 /FiO 2 ratio presented an improvement ( p <0.001; CI 99%) that continued daily up to 72 h ( p <0.001; CI 99%). Median ICU LOS was 15 days (10–28); median duration of IMV was 12 days (8–26). The ICU mortality rate was 31.6%. Lower PEEP strategy treatment in L-type COVID-19 ARDS resulted in a PaO 2 /FiO 2 ratio persistent daily improvement during the first 72 h of IMV. A lower PEEP strategy could be beneficial in the first phase of ARDS in critically ill COVID-19 patients.

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  1. Version published to 10.1007/s42399-021-01031-x
  2. Version published to 10.21203/rs.3.rs-443459/v1 on Research Square
  3. ScreenIT

    SciScore for 10.1101/2020.05.03.20089318: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: Ethics Committee permissions: This study has been notified to the Ethics Committees of Canton Ticino.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    3.6.1 and the Kaplan-Meier estimator from CRAN “surv” package.
    CRAN
    suggested: (CRAN, RRID:SCR_003005)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Our study was burdened by several limitations. First, it was a monocentric observational retrospective study, with a relatively small series of patients. Second, our comparison with current literature is performed on different patient populations, even if cohorts could be considered similar in terms of disease severity and biochemical investigations. This notwithstanding, early data are very encouraging and needs a validation in bigger prospective studies. In conclusion, the implementation of a multimodal “holistic” approach for COVID-19 patients is highly recommended. We implemented EWS monitoring for intermediate care patients, in order to perform a strict selection of ICU admission and employ MV as little as necessary. MV ventilation was adapted to the real patient needs – i.e. PEEP tailored to patient’s BMI - in order to reduce alveolar traumatism. Anticoagulation screening and therapy has been regulated in order to prevent any sign of thrombosis or thromboembolism. This multimodal program allowed us to reduce the number of ICU admissions, the number of ventilation days and mortality, and could be the base for a further specific patients’ management in this specific contest.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  4. Version published to 10.1101/2020.05.03.20089318v1 on medRxiv