Noninvasive Ventilatory Support of Patients with COVID-19 outside the Intensive Care Units (WARd-COVID)

Bellani, Giacomo; Grasselli, Giacomo; Cecconi, Maurizio; Antolini, Laura; Borelli, Massimo; De Giacomi, Federica; Bosio, Giancarlo; Latronico, Nicola; Filippini, Matteo; Gemma, Marco; Giannotti, Claudia; Antonini, Benvenuto; Petrucci, Nicola; Zerbi, Simone Maria; Maniglia, Paolo; Castelli, Gian Paolo; Marino, Giovanni; Subert, Matteo; Citerio, Giuseppe; Radrizzani, Danilo; Mediani, Teresa S.; Lorini, Ferdinando Luca; Russo, Filippo Maria; Faletti, Angela; Beindorf, Andrea; Covello, Remo Daniel; Greco, Stefano; Bizzarri, Marta M.; Ristagno, Giuseppe; Mojoli, Francesco; Pradella, Andrea; Severgnini, Paolo; Da Macallè, Marta; Albertin, Andrea; Ranieri, V. Marco; Rezoagli, Emanuele; Vitale, Giovanni; Magliocca, Aurora; Cappelleri, Gianluca; Docci, Mattia; Aliberti, Stefano; Serra, Filippo; Rossi, Emanuela; Valsecchi, Maria Grazia; Pesenti, Antonio

Rationale: Treatment with noninvasive ventilation (NIV) in coronavirus disease (COVID-19) is frequent. Shortage of intensive care unit (ICU) beds led clinicians to deliver NIV also outside ICUs. Data about the use of NIV in COVID-19 is limited. Objectives: To describe the prevalence and clinical characteristics of patients with COVID-19 treated with NIV outside the ICUs. To investigate the factors associated with NIV failure (need for intubation or death). Methods: In this prospective, single-day observational study, we enrolled adult patients with COVID-19 who were treated with NIV outside the ICU from 31 hospitals in Lombardy, Italy. Results: We collected data on demographic and clinical characteristics, ventilatory management, and patient outcomes. Of 8,753 patients with COVID-19 present in the hospitals on the study day, 909 (10%) were receiving NIV outside the ICU. A majority of patients (778/909; 85%) patients were treated with continuous positive airway pressure (CPAP), which was delivered by helmet in 617 (68%) patients. NIV failed in 300 patients (37.6%), whereas 498 (62.4%) patients were discharged alive without intubation. Overall mortality was 25%. NIV failure occurred in 152/284 (53%) patients with an arterial oxygen pressure (Pa(O(2)))/fraction of inspired oxygen (Fi (O(2))) ratio <150 mm Hg. Higher C-reactive protein and lower Pa(O(2))/Fi (O(2)) and platelet counts were independently associated with increased risk of NIV failure. Conclusions: The use of NIV outside the ICUs was common in COVID-19, with a predominant use of helmet CPAP, with a rate of success >60% and close to 75% in full-treatment patients. C-reactive protein, Pa(O(2))/Fi (O(2)), and platelet counts were independently associated with increased risk of NIV failure. Clinical trial registered with ClinicalTrials.gov (NCT04382235).