Observational study of changes in utilization and outcomes in mechanical ventilation in COVID-19

  1. Christian Karagiannidis
  2. Corinna Hentschker
  3. Michael Westhoff
  4. Steffen Weber-Carstens
  5. Uwe Janssens
  6. Stefan Kluge
  7. Michael Pfeifer
  8. Claudia Spies
  9. Tobias Welte
  10. Rolf Rossaint
  11. Carina Mostert
  12. Wolfram Windisch

Reviewed by

Read the full article

Listed in

Log in to save this article

Abstract

The role of non-invasive ventilation (NIV) in severe COVID-19 remains a matter of debate. Therefore, the utilization and outcome of NIV in COVID-19 in an unbiased cohort was determined.

Aim

The aim was to provide a detailed account of hospitalized COVID-19 patients requiring non-invasive ventilation during their hospital stay. Furthermore, differences of patients treated with NIV between the first and second wave are explored.

Methods

Confirmed COVID-19 cases of claims data of the Local Health Care Funds with non-invasive and/or invasive mechanical ventilation (MV) in the spring and autumn pandemic period in 2020 were comparable analysed.

Results

Nationwide cohort of 17.023 cases (median/IQR age 71/61–80 years, 64% male) 7235 (42.5%) patients primarily received IMV without NIV, 4469 (26.3%) patients received NIV without subsequent intubation, and 3472 (20.4%) patients had NIV failure (NIV-F), defined by subsequent endotracheal intubation. The proportion of patients who received invasive MV decreased from 75% to 37% during the second period. Accordingly, the proportion of patients with NIV exclusively increased from 9% to 30%, and those failing NIV increased from 9% to 23%. Median length of hospital stay decreased from 26 to 21 days, and duration of MV decreased from 11.9 to 7.3 days. The NIV failure rate decreased from 49% to 43%. Overall mortality increased from 51% versus 54%. Mortality was 44% with NIV-only, 54% with IMV and 66% with NIV-F with mortality rates steadily increasing from 62% in early NIV-F (day 1) to 72% in late NIV-F (>4 days).

Conclusions

Utilization of NIV rapidly increased during the autumn period, which was associated with a reduced duration of MV, but not with overall mortality. High NIV-F rates are associated with increased mortality, particularly in late NIV-F.

Article activity feed

  1. Version published to 10.1371/journal.pone.0262315
  2. Version published to 10.1101/2021.03.28.21254477v2 on medRxiv
  3. ScreenIT

    SciScore for 10.1101/2021.03.28.21254477: (What is this?)

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

    Table 1: Rigor

    Institutional Review Board StatementIACUC: The study was approved by the local ethical committee (University Witten/Herdecke, 92/2020).
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    No key resources detected.

    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:
    Most importantly, the present analysis shows that NIV has been clearly established in the treatment of severe respiratory failure attributable to COVID-19 in a real-life setting without resource limitations. Thereby, the overall duration of MV and hospital stay could be shortened. The decreasing NIV-F rate also suggests a learning curve that has occurred over the course of the last year, but may also be related to treatment successes outside MV, such as corticosteroids 21,22. The present analysis, however, also demonstrates that clinicians should apply NIV cautiously as NIV-F continues to occur frequently, which is associated with increased mortality. Therefore, NIV certainly cannot replace invasive MV in the majority of MV patients. The rather short median duration of NIV of 2.5 days in those patients successfully treated by NIV suggests that early improvements in respiratory function following NIV identify those patients who have been successfully treated and do not need intubation. In contrast, a longer duration of NIV, particularly exceeding 3–5 days, increases the likelihood of NIV-F, which is associated with an increased mortality. There are many other reports in the literature also showing the potential of NIV in the treatment of COVID-19-associated respiratory failure 23-25, and this might also have encouraged clinicians to more frequently and extensively apply NIV in this setting. In these reports, NIV was reasonably used outside the ICU, in part aimed at overcoming ...

    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 10.1101/2021.03.28.21254477v1 on medRxiv