Providing Care for Developing Respiratory Failure During Mass Admission of Patients with COVID-19

The COVID-19 pandemic has posed an unprecedented challenge to healthcare systems around the world. The mass influx of patients with severe hypoxemic respiratory failure, often progressing to acute respiratory distress syndrome (ARDS), has led to an acute shortage of beds in intensive care units (ICUs).
The aim of the study was to evaluate the effectiveness of an organizational model for the care of patients with severe COVID-19 pneumonia, including the creation of intensive observation wards (IOWs) for non-invasive respiratory support outside the ICU, and to develop a prognostic model for the risk of transferring patients to invasive mechanical ventilation (IMV) or non-invasive mechanical ventilation (NIMV).
Materials and methods. A retrospective observational study was conducted at the V. P. Demikhov city clinical hospital of the Voronovskoye Moscow clinical center for infectious diseases from January to December 2021. We analyzed data from 950 patients with confirmed COVID-19 and hypoxemic respiratory failure who started anhigh-flow oxygen therapy (HFOT) in the IOW. The demographic structure, premorbid background, clinical and laboratory parameters, and respiratory and anti-inflammatory therapy regimens (glucocorticoids — GCS: dexamethasone or methylprednisolone, and/or monoclonal antibodies — MAbs) were studied. For 573 patients transferred from the IOW to the ICU, we assessed outcomes and risk factors for the need for NIMV/IMV using binary logistic regression.
Results. Of the 950 patients who started HFOT in the IOW, 573 (60.3%) were transferred to the ICU for escalation of respiratory support. The mortality rate in the ICU group was 25.7% (147 of 573 patients hospitalized in the ICU). When comparing GCS regimens with or without MAbs, the mortality rate in patients receiving methylprednisolone in any treatment regimen was lower than in patients receiving dexamethasone: 14.1% vs. 25.8% (with MAbs, p 0.001) and 15.3% vs. 37.4% (GCS only, p 0.001). According to the logistic regression model, predictors of increased risk for the need for NIMV/IMV were: older age (OR   1.014 for each year [1.024; 1.058], presence of diabetes mellitus (OR   1.530 [1.038; 2.2123]), and a higher NEWS score upon transfer to the ICU (OR   1.342 for each score [1.153;1.562]). The use of methylprednisolone compared to dexamethasone was associated with a reduced risk of requiring NIMV/IMV (OR = 0.346 [0.238; 0.503]).
Conclusion. The organization of IOW for the implementation of HFOT according to a strict protocol made it possible to provide assistance to a large number of patients in conditions of ICU resource shortages. The use of methylprednisolone was associated with lower mortality in the ICU compared to dexamethasone. The developed prognostic model may be useful for stratifying the risks of escalating respiratory support methods and making timely decisions to transfer patients to non-invasive/invasive mechanical ventilation.

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