Respiratory Support Techniques for COVID-19-Related ARDS in a Sub-Saharan African Country

Abstract

BackgroundLimited data from low-income countries report on respiratory support techniques in COVID-19-associated ARDS.Research QuestionWhich respiratory support techniques are used in patients with COVID-19-associated ARDS in Uganda?Study Design and MethodsA multicenter, prospective, observational study was conducted at 13 Ugandan hospitals during the pandemic and included adults with COVID-19-associated ARDS. Patient characteristics, clinical and laboratory data, initial and most advanced respiratory support techniques, and 28-day mortality were recorded. Standard tests, log-rank tests, and logistic regression analyses were used for statistical analyses.ResultsFour hundred ninety-nine patients with COVID-19-associated ARDS (mild, n = 137; moderate, n = 247; and severe, n = 115) were included (ICU admission, 38.9%). Standard oxygen therapy (SOX), high-flow nasal oxygen (HFNO), CPAP, noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) was used as the first-line (most advanced) respiratory support technique in 37.3% (35.3%), 10% (9.4%), 11.6% (4.8%), 23.4% (14.4%), and 17.6% (36.6%) of patients, respectively. The first-line respiratory support technique was escalated in 19.8% of patients. Twenty-eight-day mortality was 51.9% (mild ARDS, 13.1%; moderate ARDS, 62.3%; severe ARDS, 75.7%; P < .001) and was associated with respiratory support techniques as follows: SOX, 19.9%; HFNO, 31.9%; CPAP, 58.3%; NIV 61.1%; and IMV, 83.9% (P < .001). Proning was used in 79 patients (15.8%; 59 of 79 awake) and was associated with lower mortality (40.5% vs 54%; P = .03). The oxygen saturation to Fio2 ratio (OR, 0.99; 95% CI, 0.98-0.99; P < .001) and respiratory rate (OR, 1.07; 95% CI, 1.03-1.12; P = .002) at admission and NIV (OR, 6.31; 95% CI, 2.29-17.37; P < .001) or IMV (OR, 8.08; 95% CI, 3.52-18.57; P < .001) use were independent risk factors for death.InterpretationSOX, HFNO, CPAP, NIV, and IMV were used as respiratory support techniques in patients with COVID-19-associated ARDS in Uganda. Although these data are observational, they suggest that the use of SOX and HFNO therapy as well as awake proning are associated with a lower mortality resulting from COVID-19-associated ARDS in a resource-limited setting. Limited data from low-income countries report on respiratory support techniques in COVID-19-associated ARDS. Which respiratory support techniques are used in patients with COVID-19-associated ARDS in Uganda? A multicenter, prospective, observational study was conducted at 13 Ugandan hospitals during the pandemic and included adults with COVID-19-associated ARDS. Patient characteristics, clinical and laboratory data, initial and most advanced respiratory support techniques, and 28-day mortality were recorded. Standard tests, log-rank tests, and logistic regression analyses were used for statistical analyses. Four hundred ninety-nine patients with COVID-19-associated ARDS (mild, n = 137; moderate, n = 247; and severe, n = 115) were included (ICU admission, 38.9%). Standard oxygen therapy (SOX), high-flow nasal oxygen (HFNO), CPAP, noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) was used as the first-line (most advanced) respiratory support technique in 37.3% (35.3%), 10% (9.4%), 11.6% (4.8%), 23.4% (14.4%), and 17.6% (36.6%) of patients, respectively. The first-line respiratory support technique was escalated in 19.8% of patients. Twenty-eight-day mortality was 51.9% (mild ARDS, 13.1%; moderate ARDS, 62.3%; severe ARDS, 75.7%; P < .001) and was associated with respiratory support techniques as follows: SOX, 19.9%; HFNO, 31.9%; CPAP, 58.3%; NIV 61.1%; and IMV, 83.9% (P < .001). Proning was used in 79 patients (15.8%; 59 of 79 awake) and was associated with lower mortality (40.5% vs 54%; P = .03). The oxygen saturation to Fio2 ratio (OR, 0.99; 95% CI, 0.98-0.99; P < .001) and respiratory rate (OR, 1.07; 95% CI, 1.03-1.12; P = .002) at admission and NIV (OR, 6.31; 95% CI, 2.29-17.37; P < .001) or IMV (OR, 8.08; 95% CI, 3.52-18.57; P < .001) use were independent risk factors for death. SOX, HFNO, CPAP, NIV, and IMV were used as respiratory support techniques in patients with COVID-19-associated ARDS in Uganda. Although these data are observational, they suggest that the use of SOX and HFNO therapy as well as awake proning are associated with a lower mortality resulting from COVID-19-associated ARDS in a resource-limited setting. FOR EDITORIAL COMMENT, SEE PAGE 275Take-home PointsStudy Question: What respiratory support techniques were used among patients with COVID-19-related ARDS in a resource-constrained sub-Saharan African country?Results: In 499 patients with a first diagnosis of COVID-19-related ARDS seeking treatment at 13 hospitals in Uganda, standard oxygen therapy, high-flow nasal oxygen, CPAP, noninvasive mechanical ventilation, and invasive mechanical ventilation were used as the first-line respiratory support technique in 37.3%, 10%, 11.6%, 23.4%, and 17.6% of patients, respectively. Only 38.9% of patients were admitted to the ICU, and prone positioning was used in 79 patients (15.8%). Twenty-eight-day mortality was 51.9%.Interpretation: Standard oxygen therapy, high-flow nasal oxygen, CPAP, noninvasive mechanical ventilation, and invasive mechanical ventilation were used as respiratory support techniques in patients with COVID-19-associated ARDS in Uganda. The need for escalation to advanced respiratory support (especially mechanical ventilation) and resource constraints were associated with a high mortality in this population. FOR EDITORIAL COMMENT, SEE PAGE 275 Study Question: What respiratory support techniques were used among patients with COVID-19-related ARDS in a resource-constrained sub-Saharan African country? Results: In 499 patients with a first diagnosis of COVID-19-related ARDS seeking treatment at 13 hospitals in Uganda, standard oxygen therapy, high-flow nasal oxygen, CPAP, noninvasive mechanical ventilation, and invasive mechanical ventilation were used as the first-line respiratory support technique in 37.3%, 10%, 11.6%, 23.4%, and 17.6% of patients, respectively. Only 38.9% of patients were admitted to the ICU, and prone positioning was used in 79 patients (15.8%). Twenty-eight-day mortality was 51.9%. Interpretation: Standard oxygen therapy, high-flow nasal oxygen, CPAP, noninvasive mechanical ventilation, and invasive mechanical ventilation were used as respiratory support techniques in patients with COVID-19-associated ARDS in Uganda. The need for escalation to advanced respiratory support (especially mechanical ventilation) and resource constraints were associated with a high mortality in this population. ARDS is the most common and lethal complication associated with SARS-CoV-2 infection.1Li Q. Guan X. Wu P. et al.Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia.N Engl J Med. 2020; 382: 1199-1207Crossref PubMed Scopus (10432) Google Scholar Different respiratory support techniques, including standard oxygen therapy (SOX), high-flow nasal oxygen (HFNO) therapy, CPAP, noninvasive mechanical ventilation (NIV), and invasive mechanical ventilation (IMV) have been used during the management of COVID-19-associated ARDS.2COVIS-ICU Group on behalf of the REVA Network and the COVID-ICU InvestigatorsClinical characteristics and day-90 outcomes of 4244 critically ill adults with COVID-19: a prospective cohort study.Intensive Care Med. 2021; 47: 60-73Crossref PubMed Scopus (518) Google Scholar,3Nasa P. Azoulay E. Khanna A.K. et al.Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method.Crit Care. 2021; 25: 106Crossref PubMed Scopus (112) Google Scholar Some recent practice guidelines have recommended that in patients with refractory hypoxemic respiratory failure despite SOX, HFNO is preferred over NIV where possible, and only if HFNO is not available and no urgent indication exists for endotracheal intubation, should a trial of NIV with close monitoring be considered.3Nasa P. Azoulay E. Khanna A.K. et al.Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method.Crit Care. 2021; 25: 106Crossref PubMed Scopus (112) Google Scholar,4Alhazzani W. Evans L. Alshamsi F. et al.Surviving Sepsis Campaign guidelines on the management of adults with coronavirus disease 2019 (COVID-19) in the ICU: first update.Crit Care Med. 2021; 49: e219-e234Crossref PubMed Scopus (242) Google Scholar It is important to acknowledge that all recommendations on the indication and choice of respiratory support techniques in COVID-19-associated ARDS are based on weak scientific evidence that almost exclusively originates from high- and middle-income countries.5Rochwerg B. Granton D. Wang D.X. et al.High flow nasal cannula compared with conventional oxygen therapy for acute hypoxemic respiratory failure: a systematic review and meta-analysis.Intensive Care Med. 2019; 45: 563-572PubMed Google Scholar Although pragmatic recommendations were made for low- to middle-income countries,6Serpa Neto A. Checkley W. Sivakorn C. et al.Pragmatic recommendations for the management of acute respiratory failure and mechanical ventilation in patients with COVID-19 in low- and middle-income countries.Am J Trop Med Hyg. 2021; 104: 60-71PubMed Google Scholar limited data have described the practice of respiratory support used for patients with COVID-19 ARDS in these settings. This is of relevance because many low- to middle-income countries have been burdened significantly by the COVID-19 pandemic, with limited critical care capacities contributing to mortality rates for critically ill patients admitted to high-dependency units or ICUs in Africa reported to be higher than almost everywhere else in the world.7African COVID-19 Critical Care Outcomes Study InvestigatorsPatient care and clinical outcomes for patients with COVID-19 infection admitted to African high-care or intensive care units (ACCCOS): a multicentre, prospective, observational cohort study.Lancet. 2021; 397: 1885-1894Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar When extrapolating evidence on the respiratory management of COVID-19-associated ARDS from resource-rich to resource-poor settings, it is crucial to remember that certain critical care interventions known to improve patient outcomes in high-income settings (eg, fluid resuscitation, early enteral nutrition) have been associated with harm when implemented in low- to middle-income country settings.8Andrews B. Semler M.W. Muchemwa L. et al.Effect of an early resuscitation protocol on in-hospital mortality among adults with sepsis and hypotension: a randomized clinical trial.JAMA. 2017; 318: 1233-1240Crossref PubMed Scopus (268) Google Scholar,9Maude R.J. Hoque G. Hasan et of enteral in in resource-poor a randomized PubMed Scopus Google Scholar In this to the clinical use and outcomes of respiratory support techniques in patients with COVID-19-associated ARDS admitted to 13 Ugandan hospitals during the COVID-19 conducted a prospective observational cohort study at 13 Ugandan hospitals n = n = and n = that as COVID-19 The study from The study protocol was and by the of the of was from all study or of in where the patient was ill to were the to and In of the pandemic, where to patients was limited by infection for a of for of was to prospective review of Some patients in this study were included in a observational = the and outcomes of acute hypoxemic respiratory failure in Uganda. patients because of COVID-19-associated acute hypoxemic respiratory failure at of the study the for ARDS at admission were for study COVID-19 was with the use of to SARS-CoV-2 in from or In with the W. et and outcomes of the acute respiratory using the of the J Care Med. PubMed Scopus Google Scholar ARDS as acute hypoxemic respiratory failure oxygen saturation to Fio2 ratio of < and on or that were not by failure or fluid patients with or COVID-19 as of COVID-19 management on the to Fio2 ARDS was as to Fio2 moderate to Fio2 or severe to Fio2 < at were in a at admission by the were The respiratory support techniques were in this study SOX, HFNO, CPAP, NIV, and SOX was as oxygen nasal or an oxygen HFNO was as of and oxygen at flow rates of was as of a a NIV was as support during ventilation an endotracheal or was as In to the COVID-19 pandemic, the Ugandan a of hospitals to as COVID-19 treatment and a COVID-19 was and where capacities this included of patients with COVID-19 to the COVID-19 and of ill patients to the COVID-19 at the including the COVID-19 as well as the 13 study were with oxygen, oxygen to SOX, and for the in-hospital care of patients with In these COVID-19 treatment were with respiratory support as HFNO and as well as mechanical to NIV, IMV, or ICUs were available in and all were for COVID-19 hospitals a high-dependency for during the pandemic all study ICUs and exclusively admitted COVID-19 patients. of these hospitals or The clinical management of patients with COVID-19 at study was based on guidelines by the Ugandan of of of guidelines for the management of of of Uganda, Scholar oxygen therapy was to a of oxygen was nasal or a with a and was to the this not be with SOX, therapy was escalated to an advanced respiratory support as and as by the Although HFNO, CPAP, and NIV therapy be and IMV was only in an setting. treatment at of the study hospitals an IMV were to an care with an and where study patients to The data were by at admission in all study and of respiratory Fio2 from oxygen flow rates and oxygen as by the from the of in Care et study of the and outcomes of infection in intensive care PubMed Scopus Google Scholar laboratory and and and C. et of the in a resource-constrained a prospective observational 2017; PubMed Scopus Google Scholar need for a as well as the first-line respiratory support technique that was The ratio of or oxygen to respiratory rate was as the to Fio2 ratio by the respiratory B. et respiratory rate and to of nasal high-flow J Care Med. 2019; PubMed Scopus Google Scholar patients were the and the data were admission to an ICU, need for escalation of respiratory of respiratory support settings when the respiratory support was of respiratory support techniques HFNO and of and 28-day The of respiratory support was in the of SOX HFNO NIV IMV, where The of this study was to report the use of respiratory support techniques in patients with COVID-19-associated ARDS as well as in patients with of COVID-19-associated ARDS. respiratory support was escalated in study patients, the most advanced respiratory support technique to patient during the study to the settings of respiratory support techniques and to patients with of COVID-19-related ARDS. and compared the 28-day mortality associated with respiratory support techniques and with prone positioning in patients with COVID-19-related ARDS as well as of COVID-19-related ARDS. independent risk factors for 28-day mortality in all patients with COVID-19-associated ARDS. 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The first-line respiratory technique was escalated in 19.8% of study patients The need to the first-line respiratory technique among ARDS and Study respiratory support technique among patients with moderate, or severe ARDS. among patients with moderate, or severe ARDS. among patients with moderate, or severe ARDS. among patients with moderate, or severe of first-line respiratory among patients with moderate, or severe advanced respiratory support technique among patients with moderate, or severe ARDS. among patients with moderate, or severe ARDS. among patients with moderate, or severe ARDS. among patients with moderate, or severe are as HFNO = high-flow nasal IMV = invasive mechanical NIV = noninvasive SOX = standard oxygen among patients with moderate, or severe ARDS. in a are as HFNO = high-flow nasal IMV = invasive mechanical NIV = noninvasive SOX = standard oxygen settings of the most advanced respiratory support techniques used in all study patients as well as in patients with of COVID-19-associated ARDS. for HFNO and the in patients IMV, the settings of support techniques not among ARDS 28-day mortality in the study was 51.9% of the in the Study Study among patients with moderate, or severe ARDS. among patients with moderate, or severe ARDS. are as or HFNO = high-flow nasal IMV = invasive mechanical NIV = noninvasive = = among patients with moderate, or severe ARDS. in a are as or HFNO = high-flow nasal IMV = invasive mechanical NIV = noninvasive = = The 28-day mortality rates associated with the use of respiratory support techniques were as follows: SOX, HFNO, CPAP, NIV, and IMV, 83.9% not significantly by of 28-day rates among the most advanced respiratory support techniques used in study patients as or moderate ARDS at admission, not in with severe ARDS escalation of the first-line respiratory support technique an 28-day mortality when compared with patients not vs P < .001). study prone positioning (mild ARDS, moderate ARDS, severe ARDS, P = most of were awake Study prone positioning at during admission a lower 28-day mortality (40.5% than patient not during the P = Although patients with ARDS prone positioning higher 28-day mortality than patients 28-day mortality was lower in patients with moderate ARDS were with prone positioning compared with were not The to Fio2 ratio and respiratory rate at admission, as well as the use of NIV or IMV as the most advanced respiratory support were independent risk factors for 28-day was associated with 28-day mortality in patients IMV for factors for mortality to Fio2 ratio at with 28-day rate at admission, with 28-day at admission, advanced respiratory with 28-day with 28-day settings and with mortality = high-flow nasal IMV = invasive mechanical NIV = noninvasive = SOX = standard oxygen = oxygen with 28-day in a HFNO = high-flow nasal IMV = invasive mechanical NIV = noninvasive = SOX = standard oxygen = oxygen This prospective observational cohort study is to the of the first of conducted in sub-Saharan Africa to report on the use and clinical outcomes of respiratory support techniques in patients with COVID-19-associated ARDS. included 499 patients were admitted to 13 COVID-19 hospitals in Uganda. The study was conducted during a that included the first COVID-19 in The and clinical characteristics of the study reported by the recent African COVID-19 Critical Care Outcomes Study with critically ill COVID-19 in sub-Saharan COVID-19 Critical Care Outcomes Study InvestigatorsPatient care and clinical outcomes for patients with COVID-19 infection admitted to African high-care or intensive care units (ACCCOS): a multicentre, prospective, observational cohort study.Lancet. 2021; 397: 1885-1894Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar the patient of in the cohort was lower than that reported by from C. 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Sivakorn C. et al.Pragmatic recommendations for the management of acute respiratory failure and mechanical ventilation in patients with COVID-19 in low- and middle-income countries.Am J Trop Med Hyg. 2021; 104: 60-71PubMed Google Scholar the suggest that ventilation was in most study In with from high-income the during IMV in cohort were The that monitoring was not available for all at all study the Fio2 of all ARDS Neto A. Checkley W. Sivakorn C. et al.Pragmatic recommendations for the management of acute respiratory failure and mechanical ventilation in patients with COVID-19 in low- and middle-income countries.Am J Trop Med Hyg. 2021; 104: 60-71PubMed Google Scholar The 28-day mortality in this with COVID-19-associated ARDS was C. et associated with mortality among the COVID-19 patients at a PubMed Scopus Google Scholar compared with that reported from or C. 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