South west experience of continuous positive airway pressure non-invasive ventilation for covid-19

Introduction Continuous positive airway pressure non-invasive ventilation (CPAP) was recommended by NHS England for patients with COVID-19 and hypoxaemic respiratory failure either as a ceiling of treatment, trial to avoid intubation or as a bridge to intubation.1 However, In the absence of clinical trials, its role in the treatment of COVID-19 is poorly understood. We collected observational data on outcomes of patients with COVID-19 requiring CPAP. Methods Data was collected by members of the PRISM trainee research network. Patient demographics, comorbidities, Rockwood clinical frailty scale (CFS) and outcomes (death or discharge) were collected for patients requiring CPAP for hypoxaemic respiratory failure with confirmed or clinically suspected COVID-19 across 6 sites in the South West over 11 weeks from March-June 2020. Results Data was collected for 164 patients. Ages of patients ranged from 30-88 years (mean 62.13), 110 (61.1%) male. Most patients received CPAP on a respiratory ward (79.3%). A treatment escalation plan was recorded for 153 (85%) of patients on admission to hospital. Of 100 patients eligible for escalation to intensive care (ICU), 50 required intubation and invasive mechanical ventilation (IMV) despite CPAP therapy. CFS scores ranged from 1 to 7 (mean 2.5). Average CFS score those eligible for IMV was 1.75, compared to 3.67 for those who were deemed ineligible for IMV. Mortality data are shown in table 1. Average length of stay for survivors was 15.6 days (1-63). The average number of days from admission to death was 8.6 (0-48). Conclusion In our cohort of patients who received CPAP as a ceiling of treatment mortality was high, especially compared to patients eligible for invasive mechanical ventilation. We highlight the need for early treatment escalation decisions, informed discussions with patients and relatives and involvement of palliative care where appropriate. These data are potentially limited by variation in practice between sites, and further robust evidence is needed to establish patient selection and timing of CPAP.

S96 South West experience of continuous positive airway pressure non-invasive ventilation for COVID-19

S96 Table 1Mortality of different patient groups. *p<0.01 comparing mortality of those who received CPAP as a ceiling of care vs those eligible for IMV. Number (n) Mortality (%) All patients 164 68 (41.5%) Patient who received CPAP as ceiling of treatment 64 47 (73.4%) Patients eligible for IMV 100 21 (21%)* Patients who required intubation and IMV 50 19 (38%) Patients eligible for intubation but in whom this was not required 50 2 (4%) CFS score 1–4 (non-frail) 151 59 (39.1%) CFS 5–7 (frail). NB No patient had CFS score above 7 13 9 (69.2%) ConclusionIn our cohort of patients who received CPAP as a ceiling of treatment mortality was high, especially compared to patients eligible for invasive mechanical ventilation. We highlight the need for early treatment escalation decisions, informed discussions with patients and relatives and involvement of palliative care where appropriate. These data are potentially limited by variation in practice between sites, and further robust evidence is needed to establish patient selection and timing of CPAP.ReferenceNHS England and NHS Improvement Guidance for the role and use of non-invasive respiratory support in adult patients with COVID19 (confirmed or suspected), 6 April 2020, Version 3.