ABSTRACT
BACKGROUND: Uncertainty about the optimal respiratory support strategies in critically ill COVID-19 patients is widespread. While the risks and benefits of noninvasive techniques versus early invasive mechanical ventilation (IMV) are intensely debated, actual evidence is lacking. We sought to assess the risks and benefits of different respiratory support strategies, employed in intensive care units during the first months of the COVID-19 pandemic on intubation and intensive care unit (ICU) mortality rates. METHODS: Subanalysis of a prospective, multinational registry of critically ill COVID-19 patients. Patients were subclassified into standard oxygen therapy ≥10 L/min (SOT), high-flow oxygen therapy (HFNC), noninvasive positive-pressure ventilation (NIV), and early IMV, according to the respiratory support strategy employed at the day of admission to ICU. Propensity score matching was performed to ensure comparability between groups. RESULTS: Initially, 1421 patients were assessed for possible study inclusion. Of these, 351 patients (85 SOT, 87 HFNC, 87 NIV, and 92 IMV) remained eligible for full analysis after propensity score matching. 55% of patients initially receiving noninvasive respiratory support required IMV. The intubation rate was lower in patients initially ventilated with HFNC and NIV compared to those who received SOT (SOT: 64%, HFNC: 52%, NIV: 49%, p = 0.025). Compared to the other respiratory support strategies, NIV was associated with a higher overall ICU mortality (SOT: 18%, HFNC: 20%, NIV: 37%, IMV: 25%, p = 0.016). CONCLUSION: In this cohort of critically ill patients with COVID-19, a trial of HFNC appeared to be the most balanced initial respiratory support strategy, given the reduced intubation rate and comparable ICU mortality rate. Nonetheless, considering the uncertainty and stress associated with the COVID-19 pandemic, SOT and early IMV represented safe initial respiratory support strategies. The presented findings, in agreement with classic ARDS literature, suggest that NIV should be avoided whenever possible due to the elevated ICU mortality risk.
Subject(s)
COVID-19/therapy , Critical Illness/therapy , Respiratory Therapy/methods , Respiratory Therapy/statistics & numerical data , Aged , COVID-19/mortality , Critical Illness/mortality , Disease Progression , Female , Hospital Mortality , Humans , Intensive Care Units , Male , Middle Aged , Prospective Studies , Registries , Retrospective Studies , Time Factors , Treatment OutcomeSubject(s)
Emergency Medical Services , Noble Gases/pharmacology , Post-Cardiac Arrest Syndrome/drug therapy , Respiratory Therapy/methods , Animals , Argon/pharmacology , Argon/therapeutic use , Carbon Monoxide/pharmacology , Carbon Monoxide/therapeutic use , Disease Models, Animal , Emergency Medical Services/methods , Emergency Medical Services/standards , Helium/pharmacology , Helium/therapeutic use , Humans , Hydrogen/pharmacology , Hydrogen/therapeutic use , Hydrogen Sulfide/pharmacology , Hydrogen Sulfide/therapeutic use , Nitric Oxide/pharmacology , Nitric Oxide/therapeutic use , Noble Gases/therapeutic use , Post-Cardiac Arrest Syndrome/physiopathology , Respiratory Therapy/standards , Respiratory Therapy/statistics & numerical data , Xenon/pharmacology , Xenon/therapeutic useSubject(s)
Coronavirus Infections , Pandemics , Pneumonia, Viral , Respiratory Insufficiency , Respiratory Therapy , Subacute Care , Aged , Ambulatory Care/methods , Ambulatory Care/organization & administration , Betacoronavirus/isolation & purification , COVID-19 , Coronavirus Infections/epidemiology , Coronavirus Infections/rehabilitation , Coronavirus Infections/therapy , Female , Humans , Italy/epidemiology , Male , Middle Aged , Pneumonia, Viral/epidemiology , Pneumonia, Viral/rehabilitation , Pneumonia, Viral/therapy , Recovery of Function , Rehabilitation Centers/statistics & numerical data , Respiratory Insufficiency/etiology , Respiratory Insufficiency/rehabilitation , Respiratory Therapy/methods , Respiratory Therapy/statistics & numerical data , SARS-CoV-2 , Subacute Care/methods , Subacute Care/statistics & numerical data , Treatment OutcomeABSTRACT
Detailed data on clinical presentations and outcomes of children with COVID-19 in Europe are still lacking. In this descriptive study, we report on 130 children with confirmed COVID-19 diagnosed by 28 centers (mostly hospitals), in 10 regions in Italy, during the first months of the pandemic. Among these, 67 (51.5%) had a relative with COVID-19 while 34 (26.2%) had comorbidities, with the most frequent being respiratory, cardiac, or neuromuscular chronic diseases. Overall, 98 (75.4%) had an asymptomatic or mild disease, 11 (8.5%) had moderate disease, 11 (8.5%) had a severe disease, and 9 (6.9%) had a critical presentation with infants below 6 months having significantly increased risk of critical disease severity (OR 5.6, 95% CI 1.3 to 29.1). Seventy-five (57.7%) children were hospitalized, 15 (11.5%) needed some respiratory support, and nine (6.9%) were treated in an intensive care unit. All recovered.Conclusion:This descriptive case series of children with COVID-19, mostly encompassing of cases enrolled at hospital level, suggest that COVID-19 may have a non-negligible rate of severe presentations in selected pediatric populations with a relatively high rates of comorbidities. More studies are needed to further understand the presentation and outcomes of children with COVID-19 in children with special needs. What is Known: ⢠There is limited evidence on the clinical presentation and outcomes of children with COVID-19 in Europe, and almost no evidence on characteristics and risk factors of severe cases. What is New: ⢠Among a case series of 130 children, mostly diagnosed at hospital level, and with a relatively high rate (26.2%) of comorbidities, about three-quarter had an asymptomatic or mild disease. ⢠However, 57.7% were hospitalized, 11.5% needed some respiratory support, and 6.9% were treated in an intensive care unit.