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17.06.2020 | COVID-19 | Research Letter | Ausgabe 1/2020 Open Access

Critical Care 1/2020

Invasive mechanical ventilation in COVID-19 patient management: the experience with 469 patients in Wuhan

Zeitschrift:
Critical Care > Ausgabe 1/2020
Autoren:
Jing Hua, Chenchen Qian, Zhibing Luo, Qiang Li, Feilong Wang
Wichtige Hinweise
Jing Hua, Chenchen Qian and Zhibing Luo contributed equally to this work.

Publisher’s Note

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Abbreviations
Covid-19
Coronavirus disease 2019
NV
No ventilation (nasal cannula oxygen)
NIV
Noninvasive ventilation (BiPAP, CPAP, or high-flow nasal oxygen)
IV
Invasive ventilation
HFNO
High-flow nasal oxygen
Dear Editor,
Since the first case of COVID-19 was reported in Wuhan, this new respiratory disease has evolved rapidly and been found in almost all the countries in the world. From our clinical experiences during managing COVID-19 patients, we observed an extremely high fatality rate in invasive ventilation (IV) patients which was astonishing and unexpected.
To validate our assumption, we collected and analyzed the data of 469 ICU COVID-19 patients who were hospitalized from February 2020 to the end of March in 13 ICUs in Wuhan. At the time of data collection, all of the patients were either discharged or deceased (Table  1).
Table 1
Centers and study periods
Centers
Study period
No. of cases
Huoshenshan Hospital (2 ICUs)
February 2 to March 31
118
Leishenshan Hospital (2 ICUs)
February 23 to March 31
41
Guanggu Hospital (2 ICUs)
February 21 to March 25
40
Taikang Hospital (2 ICUs)
February 11 to March 21
42
Zhongfaxincheng Hospital (3 ICUs)
February 8 to March 15
147
Wuhan Fifth Hospital (1 ICU)
February 20 to March 31
21
Union Hospital (1 ICU)
February 15 to March 31
60
Clinical features, laboratory results on admission, and outcomes are shown in Table  2. We found that the mortality rate in the IV group was 92%, compared to the other two groups (6.4% in the NV group, 40.8% in the NIV group). Furthermore, patients in the IV group developed a higher rate of severe comorbidities such as acute kidney injury (AKI) which required continuous renal replacement therapy (CRRT) (26.5%) compared to the NV (2.9%) and NIV (5.3%) groups. Moreover, 10 patients (8.8%) in the IV group received ECMO implementation.
Table 2
Clinical features, laboratory results on admission, and outcomes of the study patients
 
All ( n = 469)
No ventilation ( n = 204)
Invasive ventilation ( n = 113)
Noninvasive ventilation ( n = 152)
P
Age
68 ± 13
67 ± 15
71 ± 10
67 ± 13
0.030
Sex
       
0.034
 Male
266 (56.7)
108 (52.9)
76 (67.3)
82 (53.9)
 
 Female
203 (43.3)
96 (47.1)
37 (32.7)
70 (46.1)
 
Comorbidities, no. (%)
 Hypertension
240 (51.4)
99 (48.5)
56 (49.6)
85 (56.7)
0.288
 Diabetes
110 (23.6)
41 (20.1)
28 (24.8)
41 (27.3)
0.268
 Coronary artery disease
84 (18.0)
44 (21.6)
20 (17.9)
20 (13.3)
0.137
 Chronic obstructive lung disease
52 (11.1)
13 (6.4)
8 (7.1)
31 (20.7)
< 0.001
 Chronic kidney disease
42 (9.0)
21 (10.3)
8 (7.1)
13 (8.7)
0.623
Laboratory results on admission
 White blood cell count, × 10 9/L
9.4 ± 6.0
6.9 ± 3.6
12.7 ± 8.0
10.2 ± 5.2
< 0.001
 Neutrophil count, × 10 9/L
8.5 ± 9.2
5.7 ± 6.4
12.6 ± 11.9
8.6 ± 5.1
< 0.001
 Lymphocyte count, × 10 9/L
0.9 ± 0.6
1.0 ± 0.5
0.7 ± 0.8
0.9 ± 0.6
0.002
 NLR (neutrophil/lymphocyte ratio)
13.1 ± 13.5
7.8 ± 9.3
21.3 ± 16.0
13.9 ± 13.0
< 0.001
 Monocytes, count, × 10 9/L
0.5 ± 0.4
0.5 ± 0.6
0.5 ± 0.4
0.5 ± 0.3
0.947
 Platelet count, × 10 9/L
214 ± 112
225 ± 97
180 ± 123
223 ± 118
0.001
 C-reactive protein (mg/L)
78.7 ± 83.6
47.0 ± 51.4
116.1 ± 94.2
92.6 ± 93.8
< 0.001
 Procalcitonin (ng/ml)
1.9 ± 8.8
0.7 ± 4.7
2.8 ± 10.5
2.7 ± 10.9
0.078
 ALT (U/L)
47.1 ± 95.2
31.6 ± 30.2
80.8 ± 179.1
44.3 ± 40.9
< 0.001
 AST (U/L)
60.2 ± 227.0
31.2 ± 25.0
110.7 ± 429.4
60.9 ± 138.3
0.019
 Total bilirubin (μmol/L)
14.7 ± 11.5
11.0 ± 5.7
18.1 ± 13.2
16.8 ± 14.1
< 0.001
 Direct bilirubin (μmol/L)
8.1 ± 7.5
5.0 ± 5.1
9.9 ± 9.2
10.6 ± 7.3
< 0.001
 Albumin (g/L)
32.0 ± 5.6
32.7 ± 4.6
30.1 ± 7.0
32.4 ± 5.4
< 0.001
d-dimer (μg/mL)
5.9 ± 11.9
3.1 ± 5.3
13.2 ± 20.5
4.5 ± 7.0
0.276
 Glucose (mmol/L)
8.7 ± 4.7
7.1 ± 3.3
10.3 ± 6.8
9.5 ± 3.9
< 0.001
 Serum creatine (Scr) (μmol/L)
128.3 ± 190.7
124.5 ± 197.5
119.2 ± 165.2
140.2 ± 199.9
0.636
 SOFA score on day 1
4.2 ± 3.1
2.2 ± 2.2
6.0 ± 3.0
5.5 ± 2.7
< 0.001
Continuous renal replacement therapy (CRRT), no. (%)
44 (9.4)
6 (2.9)
30 (26.5)
8 (5.3)
< 0.001
Extracorporeal membrane oxygenation (ECMO), no. (%)
10 (3.1)
0 (0.0)
10 (8.8)
0 (0.0)
< 0.001
Length of hospital stay (days)
20.4 ± 13.2
27.3 ± 14.7
17.9 ± 12.3
16.1 ± 9.6
< 0.001
Mortality, no. (%)
179 (38.2)
13 (6.4)
104 (92.0)
62 (40.8)
< 0.001
The mean age in the IV group was 71, which was significantly higher than the other two groups (67 in both the NIV group and NV group, P = 0.03). There were no significant differences in comorbidities on admission except chronic obstructive pulmonary disease (COPD). Interestingly, there were even more cases of COPD in the NIV group (31, 20.7%) than in the IV group (8, 7.1%). This could be explained that physicians tend to avoid intubation in chronic lung disease patients due to concern of barotrauma and higher DNR/DNI ratio in those patients. From laboratory results, significantly higher white blood cell count, lower lymphocyte count and platelet count, and higher CRP, AST, ALT, and total bilirubin are presented in the IV group than the other two groups on admission. SOFA scores in the IV and NIV groups were also significantly higher than the NV group. There were no significant differences in Scr among these groups on admission though. We can tell from the data that the patients in the IV group were older with a higher rate of hyperinflammation status on admission compared to the other two groups. These factors may lead to the rapid progress of respiratory failure and fatal outcome eventually [ 1].
Researchers worldwide also start to realize that IV may not improve the mortality in COVID-19 patients [ 2, 3]. We have to admit that some of the COVID-19 patients who developed progressive worsening respiratory distress were refractory to NIV. Intubation is inevitable in those cases. However, sometimes physicians can be rushed to intubation. It has been reported that intubation can be successfully avoided by HFNO [ 4, 5].
As we all know, IV can cause a lot of complications including hypotension, ventilator-related infection, volume imbalance, and sedation-related delirium. The decision of intubation mostly based on clinical judgments and varies from case to case. There is a notion that NIV causes wide-spread dispersion of aerosol thus increases the risk of transmission to healthcare workers. This could be one of the reasons that encourages physicians to choose IV over NIV among clinical decisions [ 5].
In conclusion, from our data in Wuhan, COVID-19 patients who were invasively ventilated exhibited pessimistic outcomes. This suggests that early intubation may not help patients but instead, make things head towards the wrong direction. We should try to avoid IV and utilize NIV at the early stage of respiratory failure until IV is inevitable [ 6]. It is time for physicians to rethink the threshold of intubation in COVID-19 management.

Acknowledgements

None.

Ethics approval and consent to participate

The study was approved by the Shanghai East Ethics Committee.

Consent for publication

Written informed consent was waived by the Ethics Committee due to the retrospective nature of this study and rapid emergence of this infectious disease.

Competing interests

All authors declare no competing interests.
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