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. 2020 Sep;22(3):200-211.
doi: 10.1016/S1441-2772(23)00387-3.

Characteristics, treatment, outcomes and cause of death of invasively ventilated patients with COVID-19 ARDS in Milan, Italy

Alberto Zangrillo  1 , Luigi Beretta  1 , Anna Mara Scandroglio  1 , Giacomo Monti  1 , Evgeny Fominskiy  1 , Sergio Colombo  1 , Federica Morselli  1 , Alessandro Belletti  1 , Paolo Silvani  1 , Martina Crivellari  1 , Fabrizio Monaco  1 , Maria Luisa Azzolini  1 , Raffaella Reineke  1 , Pasquale Nardelli  1 , Marianna Sartorelli  1 , Carmine D Votta  1 , Annalisa Ruggeri  1 , Fabio Ciceri  2 , Francesco De Cobelli  2 , Moreno Tresoldi  3 , Lorenzo Dagna  2 , Patrizia Rovere-Querini  2 , Ary Serpa Neto  4 , Rinaldo Bellomo  4 , Giovanni Landoni  5 ; COVID-BioB Study Group
Affiliations

Characteristics, treatment, outcomes and cause of death of invasively ventilated patients with COVID-19 ARDS in Milan, Italy

Alberto Zangrillo et al. Crit Care Resusc. 2020 Sep.

Abstract

Objective: Describe characteristics, daily care and outcomes of patients with coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS).

Design: Case series of 73 patients.

Setting: Large tertiary hospital in Milan.

Participants: Mechanically ventilated patients with confirmed COVID-19 admitted to the intensive care unit (ICU) between 20 February and 2 April 2020.

Main outcome measures: Demographic and daily clinical data were collected to identify predictors of early mortality.

Results: Of the 73 patients included in the study, most were male (83.6%), the median age was 61 years (interquartile range [IQR], 54-69 years), and hypertension affected 52.9% of patients. Lymphocytopenia (median, 0.77 x 103 per mm3; IQR, 0.58-1.00 x 103 per mm3), hyperinflammation with C-reactive protein (median, 184.5 mg/dL; IQR, 108.2-269.1 mg/dL) and pro-coagulant status with D-dimer (median, 10.1 μg/m; IQR, 5.0-23.8 μg/m) were present. Median tidal volume was 6.7 mL/kg (IQR, 6.0-7.5 mL/kg), and median positive end-expiratory pressure was 12 cmH2O (IQR, 10-14 cmH2O). In the first 3 days, prone positioning (12-16 h) was used in 63.8% of patients and extracorporeal membrane oxygenation in five patients (6.8%). After a median follow-up of 19.0 days (IQR, 15.0-27.0 days), 17 patients (23.3%) had died, 23 (31.5%) had been discharged from the ICU, and 33 (45.2%) were receiving invasive mechanical ventilation in the ICU. Older age (odds ratio [OR], 1.12; 95% CI, 1.04-1.22; P = 0.004) and hypertension (OR, 6.15; 95% CI, 1.75-29.11; P = 0.009) were associated with mortality, while early improvement in arterial partial pressure of oxygen (PaO2) to fraction of inspired oxygen (FiO2) ratio was associated with being discharged alive from the ICU (P = 0.002 for interaction).

Conclusions: Despite multiple advanced critical care interventions, COVID-19 ARDS was associated with prolonged ventilation and high short term mortality. Older age and pre-admission hypertension were key mortality risk factors.

Trial registration: ClinicalTrials.gov identifier: NCT04318366.

PubMed Disclaimer

Conflict of interest statement

Lorenzo Dagna received consultation honoraria from Roche, Sanofi-Genzyme and SOBI outside of the submitted work. Ary Serpa Neto reported receiving personal fees from Dräger outside of the submitted work.

Figures

Figure 1
Figure 1
Kaplan–Meier curves for 7-day mortality (A) and cumulative incidence function of extubation and intensive care unit mortality (B)* * Data were censored at the latest follow-up (2 April 2020).
Figure 2
Figure 2
Effect of changes in Pao2/Fio2 ratio in the first 7 days on mortality and on the chance of being discharged alive from the intensive care unit (ICU) at the latest follow-up Fio2 = fraction of inspired oxygen; Pao2 = arterial partial pressure of oxygen. Panel A shows the change in the Pao2/Fio2 ratio in the first 7 days of follow-up compared with the baseline value and according to survival at the latest follow-up. Panel B shows the change in the Pao2/Fio2 ratio in the first 7 days of follow-up compared with the baseline value and according to being discharged alive from the ICU at the latest follow-up. In both plots, circles are medians and the error bars represent the interquartile range (IQR); the P value represents the interaction between the groups and the days from an unadjusted mixed-effect quantile regression based on the asymmetric Laplace distribution for continuous variables and accounting for the repeated measurements. The median difference for the interaction is 4.19 (IQR, –2.10 to 10.50; P = 0.186) for the comparison of survivors and non-survivors, and 9.64 (IQR, 3.68–15.59; P = 0.002) for the comparison of being discharged alive or not. Panel C shows a marginal effect plot with the effect of changes in the Pao2/Fio2 ratio at Day 3 on the predicted risk of mortality at the longest follow-up from a univariable generalised linear model considering a binomial distribution. The odds ratio for the change is 0.99 (95% CI, 0.99–1.00; P = 0.441). Panel D shows a marginal effect plot with the effect of changes in the Pao2/Fio2 ratio at Day 3 on the predicted risk of being discharged alive from the ICU at the longest follow-up from a univariable generalised linear model considering a binomial distribution. The odds ratio for the change is 1.01 (95% CI, 0.99–1.02; P = 0.071).
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