Ventilator avoidance among critically ill COVID-19 patients with acute respiratory distress syndrome

ABSTRACT

Introduction: Misinformation citing mechanical ventilation, not the virus, as causing death in COVID-19 patients with respiratory failure has led to ventilator avoidance (initial refusal of intubation) during the pandemic. Method(s) Prospective observational cohort study (March 2020- June 2021) evaluating the incidence and significance of initial refusal of intubation in patients with critical COVID-19 defined as ARDS requiring > 55% sustained FiO2 on high flow nasal canula (HFNC), non-invasive positive-pressure ventilation (NIPPV) or requiring intubation. Outcomes included in-hospital mortality and 1-year modified Rankin Scale (mRS) score. Logistic regression was used to estimate the age and Charlson Comorbidity Index adjusted odds ratio (OR) of in-hospital death. The Wilcoxon rank-sum test was used to evaluate differences in the mRs. Result(s) The cohort was predominantly non-Latino white (76%), male (65%), unvaccinated (99.4%), mean age of 66, and good pre- COVID-19 functional status (median mRs score of 0). Overall, 315 patients were critically ill due to COVID-19 with an in-hospital mortality of 41.9% (132/315;95% CI 36-47%). In patients in whom intubation was recommended 39% initially refused (40/102;95% CI 30-49%). Utilization of HFNC (90%) and NIPPV (72%) were similar between groups, however actual use of mechanical ventilation differed (98.4% in those that did not initially refuse compared to 20% in those that initially refused (p = 0.001)). In-hospital mortality was 79.3% (49/62) in those who initially did not refuse intubation compared to 77.5% (31/40) in those who refused (adjusted OR 1.3;95% CI 0.5-.5). The distribution of 1-year mRS was not significantly different between groups (p = 1.0) (Fig. 1). Conclusion(s) Among critically ill patients with COVID-19 associated ARDS, ventilator avoidance was common however, it was not associated with increased in-hospital mortality or a difference in 1-year functional outcome.