The Association of Non-invasive Ventilation and Mortality in COVID-19 Induced Acute Respiratory Distress Syndrome.

Background: The COVID-19 pandemic caused a major burden on the healthcare system. Since the beginning of the pandemic, the timing of intubation in patients with COVID-19 induced acute respiratory distress syndrome (ARDS) remained an area of debate.

Research question: Does a trial of non-invasive ventilation (NIV) in COVID-19 patients worsen mortality in patients intubated due to ARDS?

Study design and methods: A single-center, retrospective cohort study of all adult patients (n = 161) with COVID-19 admitted to the ICU between March 2020 through September 2022 with acute hypoxic respiratory failure were included. The group was divided into patients intubated after a trial of NIV (N = 100) and patients intubated without a trial of NIV (N = 61). The primary outcome was to compare the mortality rates between the two groups.

Measurements and main results: ICU mortality (defined as death during ICU admission) was higher in patients intubated after a trial of the NIV group compared to those without a trial of NIV (69% vs 52%, p = 0.044). Patients initially treated with a trial of NIV had an odds ratio (OR) of 2.17 for mortality compared to those intubated without a trial of NIV (95% CI 1.04-4.54). ICU length of stay was higher in the intubation after a trial of the NIV group, 11.9 vs 7.7 days (p = 0.001). Patients intubated after a trial of NIV had a longer hospital Length of stay (LOS) (IRR 1.39, 95% CI 1.05-1.85, p = 0.022). However, the duration of mechanical ventilation was similar in the two groups (IRR 1.23, 95% CI 1.93-4.68, p = 0.35). The incidence of pneumothorax, ventilator associated pneumonia (VAP), and venous thromboembolism (VTE) were similar in the two groups.

Conclusion: In ARDS, a lung protective strategy with low TV has been proven to improve patient outcomes. The use of a trial of NIV prior to intubation is associated with an increase in mortality.