Despite fully fitting the ARDS Berlin definition, the COVID-19 pneumonia in its early phase presents pathoanatomical characteristics which make the presently recommended treatment (high PEEP) highly questionable and potentially harmful. |
Introduction
Methods
Patient population
Protocol
During treatment
Measurements
Statistical analysis
Results
Standard treatment
Anatomical and physiological characteristics of CARDS
Overall (n = 140) | No ARDS (n = 17) | Mild ARDS (n = 45) | Mild-moderate ARDS (n = 33) | Moderate-severe ARDS (n = 36) | Severe ARDS (n = 9) | p value | |
---|---|---|---|---|---|---|---|
Anthropometrics | |||||||
Female (n %) | 42 (30) | 2 (12) | 11 (24.4) | 12 (36.4) | 13 (36.1) | 4 (44.4) | < 0.001* |
Age (years) | 59 [52–66] | 58 [54–62] | 59 [53–67] | 57 [51–63] | 60 [55–65] | 63 [57–69] | 0.11 |
BMI (kg/m2) | 28.1 [25.2–32.3] | 29.4 [27.8–33.2] | 28.0 [25.3–33.7] | 26.0 [24.4–29.6] | 29 [25.9–32.3] | 28.1 [27.8–30.1] | 0.98 |
Height (m) | 1.7 ± 0.09 | 1.77 ± 0.09 | 1.73 ± 0.07 | 1.67 ± 0.12 | 1.67 ± 0.09 | 1.77 ± 0.08 | 0.006* |
Duration of symptoms to admission (days) | 6 [4–8] | 7 [5–10] | 5 [4–8] | 6 [3–8] | 6 [5–8] | 5 [2–7] | 0.56 |
CPAP–NIV (n–n) | 131–9 | 16–1 | 43–2 | 30–3 | 34–2 | 8–1 | 0.90 |
Days from admission to intubation (days) | 6 [4–9] | 6 [4–7] | 4 [4–6] | 5 [5–10] | 8 [6–12] | 6 [3–8] | 0.25 |
Failure of non-invasive respiratory support (n %) | 34 [24.3] | 3 (17.6) | 7 (15.6) | 7 (21.2) | 10 (27.8) | 7 (77.8) | 0.002* |
In-hospital mortality (n %) | 14 (10) | 1 (5.9) | 1 (2.2) | 1 (3.0) | 7 (19.4) | 4 (44.4) | < 0.001* |
Laboratory | |||||||
Hemoglobin (g/dl) | 14.4 [13.2–15.4] | 14.6 [13.7–15.5] | 14.3 [13.2–15.4] | 14 [13–15] | 14.5 [13.9–15.4] | 14.6 [12.9–16.2] | 0.56 |
Platelets (109/l) | 202 [155–241] | 205 [183–266] | 202 [163–247] | 204 [159–223] | 194 [139–239] | 158 [150–218] | 0.51 |
D-dimer (ng/dl) | 298 [215–411] | 251 [172–366] | 301 [223–386] | 263 [210–391] | 287 [196–429] | 434 [344–457] | 0.49 |
INR | 1.14 [1.09–1.22] | 1.13 [1.08–1.16] | 1.14 [1.08–1.23] | 1.15 [1.09–1.22] | 1.18 [1.12–1.25] | 1.13 [1.1–1.21] | 0.41 |
aPTT (s) | 1.01 [0.92–1.08] | 1.05 [0.92–1.11] | 1.00 [0.93–1.06] | 1.04 [0.94–1.1] | 0.99 [0.91–1.07] | 0.95 [0.93–1.1] | 0.76 |
ALT (U/l) | 44 [28–67] | 47 [36–79] | 49 [30–73] | 46 [32–62] | 32 [27–65] | 30 [23–47] | 0.23 |
AST (U/l) | 55 [41–76] | 59 [43–96] | 59 [42–77] | 53 [41–74] | 52 [39–71] | 56 [37–72] | 0.87 |
Creatinine (mg/dl) | 0.8 [0.7–1] | 0.85 [0.78–1.13] | 0.85 [0.7–1] | 0.8 [0.6–0.98] | 0.9 [0.73–1.1] | 1 [0.68–1.10] | 0.32 |
Overall (n = 140) | No ARDS (n = 17) | Mild ARDS (n = 45) | Mild-moderate ARDS (n = 33) | Moderate-severe ARDS (n = 36) | Severe ARDS (n = 9) | p value | |
---|---|---|---|---|---|---|---|
Gas exchange | |||||||
PaO2 (mmHg) | 104 [79–140] | 226 [187–259] | 143 [102–151] | 112 [100–123] | 83.2 [75.9–93.6] | 65.1 [59.3–69] | < 0.001* |
FiO2 | 0.6 [0.6–0.7] | 0.6 [0.6–0.7] | 0.6 [0.5–0.7] | 0.7 [0.5–0.7] | 0.7 [0.6–0.7] | 0.8 [0.7–0.8] | < 0.001* |
PaCO2 (mmHg) | 37 [33.9–40.7] | 38.3 [32.6–42.0] | 35.9 [32.6–39] | 38.8 [35–41] | 36.5 [34.8–40.8] | 39 [34.2–39.9] | 0.37 |
pH | 7.44 [7.42–7.47] | 7.44 [7.42–7.46] | 7.45 [7.43–7.48] | 7.44 [7.43–7.47] | 7.44 [7.42–7.46] | 7.43 [7.42–7.45] | 0.52 |
Respiratory rate (bpm) | 20 [18–24] | 16 [15–20] | 21 [18–23] | 21 [18–24] | 21 [18–25] | 20 [18–20] | 0.039* |
PEEP (cmH2O) | 7.5 [7.5–10] | 10 [7.5–10] | 8 [7.5–10] | 8 [7.5–10] | 9 [7.5–10] | 10 [10–10] | 0.24 |
Esophageal pressure swing (cm H2O) | 7 [5–10] | 6 [5–7] | 7 [5–9] | 7 [4–9] | 9 [7–12] | 7 [5–7] | 0.06 |
Total stress (cm H2O) | 14 [11.5–16.3] | 13 [11.8–15] | 13.2 [11.3–16] | 13.8 [11–16] | 15.2 [12.9–18.6] | 14 [13.3–16.8] | 0.12 |
Borg dyspnea scale | 0 [0–1] | 0 [0–1] | 0 [0–0] | 0 [0–0] | 0 [0–1] | 0 [0–1] | 0.34 |
PEEP test | |||||||
SpO2 at 0 cmH2O (%) | 97 [93–99] | 98 [94–100] | 98 [96–99] | 98 [95–99] | 95 [93–98] | 91 [88–94] | 0.003* |
SpO2 at 10 cmH2O (%) | 98 [96–99] | 99 [98–100] | 99 [97–100] | 98 [97–99] | 97 [96–98] | 94 [94–98] | 0.006* |
Respiratory rate at 0 cm H2O (bpm) | 22
[18–28] | 18 [15–20] | 22 [18–28] | 23 [20–28] | 22 [19–27] | 24.5 [22–27] | 0.010* |
Respiratory rate at 10 cm H2O (bpm) | 20 [16–24] | 16 [15–18] | 20 [17–22] | 22 [18–25] | 20 [17–28] | 19.5 [18–21] | 0.007* |
Esophageal pressure swing at 0 cmH2O (cmH2O) | 8 [6–12] | 7 [5–7] | 8 [5–10] | 8 [5–12] | 8 [7–15] | 8.8 [6–11] | 0.36 |
Esophageal pressure swing at 10 cmH2O (cmH2O) | 7 [5–10] | 7.5 [6–9] | 7 [5–9] | 7 [4–9] | 9 [7–12] | 7 [6–9] | 0.07 |
Total stress at 0 cmH2O (cmH2O) | 8 [6–12] | 7 [5–10] | 8 [5–10] | 8 [5–12] | 8 [7–15] | 9 [6–11] | 0.36 |
Total stress at 10 cmH2O (cmH2O) | 14 [12–17] | 14.5 [13–16.3] | 14 [12–16] | 14 [11.3–16.3] | 16 [14–18.5] | 14 [13.4–15.6] | 0.07 |
Association between variables and outcome
Non intubated (n = 106) | Intubated (n = 34) | p value | |
---|---|---|---|
Gas exchange | |||
Respiratory rate (bpm) | 20 [18-23] | 22 [19-25] | 0.22 |
PaO2/FiO2 (mmHg) | 197 [147–245] | 149 [106–207] | 0.003* |
PaO2 (mmHg) | 114 [85–149] | 86 [69–124] | 0.004* |
PaCO2 (mmHg) | 38 [34-41] | 35 [33-39] | 0.09 |
Borg dyspnea scale | 0 [0–1] | 0 [0–1] | 0.08 |
Esophageal pressure swing (cmH2O) | 7 [5-9] | 9 [5-12] | 0.10 |
Total lung stress (cmH2O) | 13.5 [11.4–15.4] | 15.6 [13.1–19.2] | 0.018* |
Tissue mass (g) | 1101 [866–1284] | 1132 [942–1260] | 0.39 |
Gas volume (ml) | 2191 [1624–2889] | 2173 [1563–2737] | 0.82 |
Overinflated tissue (%) | 1 [0–3] | 1 [0–3] | 0.57 |
Normally inflated tissue (%) | 56 [45–63] | 53 [43–65] | 0.43 |
Poorly inflated tissue (%) | 32 [24–38] | 32 [25–40] | 0.90 |
Non-inflated tissue (%) | 9 [6–13] | 10 [8–16] | 0.26 |
PEEP test | |||
SpO2 at 0 cmH2O (%) | 98 [94–99] | 93 [92–98] | 0.005* |
SpO2 at 10 cmH2O (%) | 98 [97–99] | 97 [94–98] | 0.010* |
Esophageal pressure swing at 0 cmH2O (cmH2O) | 8 [6–10] | 12 [6–15] | 0.007* |
Esophageal pressure swing at 10 cmH2O (cmH2O) | 7 [5–9] | 11 [6–14] | 0.002* |
Respiratory rate at 0 cmH2O (bpm) | 21 [17–28] | 23 [20–28] | 0.21 |
Respiratory rate at 10 cmH2O (bpm) | 20 [16–22] | 20 [18–25] | 0.16 |