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Physiologic dead space is independently associated with mortality and discharge of mechanically ventilated patients with COVID-19 ARDS: a retrospective study.

ABSTRACT: Physiologic dead space is a well-established independent predictor of death in patients with acute respiratory distress syndrome (ARDS). Here, we explore the association between a surrogate measure of dead space (DS) and early outcomes of mechanically ventilated patients admitted to Intensive Care Unit (ICU) because of COVID-19-associated ARDS. Retrospective cohort study on data derived from Italian ICUs during the first year of the COVID-19 epidemic. A competing risk Cox proportional hazard model was applied to test for the association of DS with two competing outcomes (death or discharge from the ICU) while adjusting for confounders. The final population consisted of 401 patients from seven ICUs. A significant association of DS with both death (HR 1.204; CI 1.019-1.423; p = 0.029) and discharge (HR 0.434; CI 0.414-0.456; p [Formula: see text]) was noticed even when correcting for confounding factors (age, sex, chronic obstructive pulmonary disease, diabetes, PaO[Formula: see text]/FiO[Formula: see text], tidal volume, positive end-expiratory pressure, and systolic blood pressure). These results confirm the important association between DS and death or ICU discharge in mechanically ventilated patients with COVID-19-associated ARDS. Further work is needed to identify the optimal role of DS monitoring in this setting and to understand the physiological mechanisms underlying these associations.

SUBMITTER: Mollura M

PROVIDER: S-EPMC10081332 | biostudies-literature | 2023 Apr

REPOSITORIES: biostudies-literature

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Physiologic dead space is independently associated with mortality and discharge of mechanically ventilated patients with COVID-19 ARDS: a retrospective study.

Mollura Maximiliano M Baroncelli Francesca F Mandelli Giulia G Tricella Giovanni G Weissman Gary E GE Poole Daniele D Caironi Pietro P Celi Leo Anthony LA Barbieri Riccardo R Finazzi Stefano S

Scientific reports 20230407 1

Physiologic dead space is a well-established independent predictor of death in patients with acute respiratory distress syndrome (ARDS). Here, we explore the association between a surrogate measure of dead space (DS) and early outcomes of mechanically ventilated patients admitted to Intensive Care Unit (ICU) because of COVID-19-associated ARDS. Retrospective cohort study on data derived from Italian ICUs during the first year of the COVID-19 epidemic. A competing risk Cox proportional hazard mod ...[more]

PMID: 37029215

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Project description:BackgroundEstimates for dead space ventilation have been shown to be independently associated with an increased risk of mortality in the acute respiratory distress syndrome and small case series of COVID-19-related ARDS.MethodsSecondary analysis from the PRoVENT-COVID study. The PRoVENT-COVID is a national, multicenter, retrospective observational study done at 22 intensive care units in the Netherlands. Consecutive patients aged at least 18 years were eligible for participation if they had received invasive ventilation for COVID-19 at a participating ICU during the first month of the national outbreak in the Netherlands. The aim was to quantify the dynamics and determine the prognostic value of surrogate markers of wasted ventilation in patients with COVID-19-related ARDS.ResultsA total of 927 consecutive patients admitted with COVID-19-related ARDS were included in this study. Estimations of wasted ventilation such as the estimated dead space fraction (by Harris-Benedict and direct method) and ventilatory ratio were significantly higher in non-survivors than survivors at baseline and during the following days of mechanical ventilation (p < 0.001). The end-tidal-to-arterial PCO2 ratio was lower in non-survivors than in survivors (p < 0.001). As ARDS severity increased, mortality increased with successive tertiles of dead space fraction by Harris-Benedict and by direct estimation, and with an increase in the VR. The same trend was observed with decreased levels in the tertiles for the end-tidal-to-arterial PCO2 ratio. After adjustment for a base risk model that included chronic comorbidities and ventilation- and oxygenation-parameters, none of the dead space estimates measured at the start of ventilation or the following days were significantly associated with 28-day mortality.ConclusionsThere is significant impairment of ventilation in the early course of COVID-19-related ARDS but quantification of this impairment does not add prognostic information when added to a baseline risk model.Trial registrationISRCTN04346342. Registered 15 April 2020. Retrospectively registered.

Project description:BackgroundPassive immunization with plasma collected from convalescent patients has been regularly used to treat coronavirus disease 2019 (Covid-19). Minimal data are available regarding the use of convalescent plasma in patients with Covid-19-induced acute respiratory distress syndrome (ARDS).MethodsIn this open-label trial, we randomly assigned adult patients with Covid-19-induced ARDS who had been receiving invasive mechanical ventilation for less than 5 days in a 1:1 ratio to receive either convalescent plasma with a neutralizing antibody titer of at least 1:320 or standard care alone. Randomization was stratified according to the time from tracheal intubation to inclusion. The primary outcome was death by day 28.ResultsA total of 475 patients underwent randomization from September 2020 through March 2022. Overall, 237 patients were assigned to receive convalescent plasma and 238 to receive standard care. Owing to a shortage of convalescent plasma, a neutralizing antibody titer of 1:160 was administered to 17.7% of the patients in the convalescent-plasma group. Glucocorticoids were administered to 466 patients (98.1%). At day 28, mortality was 35.4% in the convalescent-plasma group and 45.0% in the standard-care group (P = 0.03). In a prespecified analysis, this effect was observed mainly in patients who underwent randomization 48 hours or less after the initiation of invasive mechanical ventilation. Serious adverse events did not differ substantially between the two groups.ConclusionsThe administration of plasma collected from convalescent donors with a neutralizing antibody titer of at least 1:160 to patients with Covid-19-induced ARDS within 5 days after the initiation of invasive mechanical ventilation significantly reduced mortality at day 28. This effect was mainly observed in patients who underwent randomization 48 hours or less after ventilation initiation. (Funded by the Belgian Health Care Knowledge Center; ClinicalTrials.gov number, NCT04558476.).

Project description:BackgroundSome unanswered questions persist regarding the effectiveness of corticosteroids for severe coronavirus disease 2019 (COVID-19) patients. We aimed to assess the clinical effect of corticosteroids on intensive care unit (ICU) mortality among mechanically ventilated COVID-19-associated acute respiratory distress syndrome (ARDS) patients.MethodsThis was a retrospective study of prospectively collected data conducted in 70 ICUs (68 Spanish, one Andorran, one Irish), including mechanically ventilated COVID-19-associated ARDS patients admitted between February 6 and September 20, 2020. Individuals who received corticosteroids for refractory shock were excluded. Patients exposed to corticosteroids at admission were matched with patients without corticosteroids through propensity score matching. Primary outcome was all-cause ICU mortality. Secondary outcomes were to compare in-hospital mortality, ventilator-free days at 28 days, respiratory superinfection and length of stay between patients with corticosteroids and those without corticosteroids. We performed survival analysis accounting for competing risks and subgroup sensitivity analysis.ResultsWe included 1835 mechanically ventilated COVID-19-associated ARDS, of whom 1117 (60.9%) received corticosteroids. After propensity score matching, ICU mortality did not differ between patients treated with corticosteroids and untreated patients (33.8% vs. 30.9%; p = 0.28). In survival analysis, corticosteroid treatment at ICU admission was associated with short-term survival benefit (HR 0.53; 95% CI 0.39-0.72), although beyond the 17th day of admission, this effect switched and there was an increased ICU mortality (long-term HR 1.68; 95% CI 1.16-2.45). The sensitivity analysis reinforced the results. Subgroups of age < 60 years, severe ARDS and corticosteroids plus tocilizumab could have greatest benefit from corticosteroids as short-term decreased ICU mortality without long-term negative effects were observed. Larger length of stay was observed with corticosteroids among non-survivors both in the ICU and in hospital. There were no significant differences for the remaining secondary outcomes.ConclusionsOur results suggest that corticosteroid treatment for mechanically ventilated COVID-19-associated ARDS had a biphasic time-dependent effect on ICU mortality. Specific subgroups showed clear effect on improving survival with corticosteroid use. Therefore, further research is required to identify treatment-responsive subgroups among the mechanically ventilated COVID-19-associated ARDS patients.

Dataset Information

Physiologic dead space is independently associated with mortality and discharge of mechanically ventilated patients with COVID-19 ARDS: a retrospective study.

Publications

Physiologic dead space is independently associated with mortality and discharge of mechanically ventilated patients with COVID-19 ARDS: a retrospective study.

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