Sixty-Day Mortality Among 520 Italian Hospitalized COVID-19 Patients According to the Adopted Ventilatory Strategy in the Context of an Integrated Multidisciplinary Clinical Organization: A Population-Based Cohort Study

Antonella Potalivo; Jonathan Montomoli; Francesca Facondini; Gianfranco Sanson; Luigi Arcangelo Lazzari Agli; Tiziana Perin; Francesco Cristini; Enrico Cavagna; Raffaella De Giovanni; Carlo Biagetti; Ilaria Panzini; Cinzia Ravaioli; Maria Maddalena Bitondo; Daniela Guerra; Giovanni Giuliani; Elena Mosconi; Sonia Guarino; Elisa Marchionni; Gianfilippo Gangitano; Ilaria Valentini; Luca Giampaolo; Francesco Muratore; Giuseppe Nardi

doi:10.2147/CLEP.S278709

Sixty-Day Mortality Among 520 Italian Hospitalized COVID-19 Patients According to the Adopted Ventilatory Strategy in the Context of an Integrated Multidisciplinary Clinical Organization: A Population-Based Cohort Study

Clin Epidemiol. 2020 Dec 30:12:1421-1431. doi: 10.2147/CLEP.S278709. eCollection 2020.

Authors

Antonella Potalivo^#¹, Jonathan Montomoli^#¹, Francesca Facondini¹, Gianfranco Sanson², Luigi Arcangelo Lazzari Agli^{3

4}, Tiziana Perin⁵, Francesco Cristini⁶, Enrico Cavagna⁷, Raffaella De Giovanni⁸, Carlo Biagetti⁶, Ilaria Panzini⁹, Cinzia Ravaioli¹⁰, Maria Maddalena Bitondo¹, Daniela Guerra¹, Giovanni Giuliani¹, Elena Mosconi¹, Sonia Guarino¹, Elisa Marchionni⁶, Gianfilippo Gangitano⁵, Ilaria Valentini^{3

4}, Luca Giampaolo⁸, Francesco Muratore⁷, Giuseppe Nardi¹

Affiliations

¹ Department of Anaesthesia and Intensive Care, Infermi Hospital, AUSL della Romagna, Rimini, Italy.
² Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy.
³ Department of Pneumology, Infermi Hospital, Rimini, Italy.
⁴ Ceccarini Hospital, AUSL della Romagna, Riccione, Italy.
⁵ Department of Emergency Medicine, Infermi Hospital, AUSL Della Romagna, Rimini, Italy.
⁶ Department of Infectious Diseases, Infermi Hospital, AUSL della Romagna, Rimini, Italy.
⁷ Department of Radiology, Infermi Hospital, AUSL della Romagna, Rimini, Italy.
⁸ Department of Internal Medicine, Cervesi Hospital, AUSL della Romagna, Cattolica, Italy.
⁹ Department of Clinical Research, AUSL della Romagna, Ravenna, Italy.
¹⁰ Ausl della Romagna Health Care Service Direction, Ravenna, Italy.

^# Contributed equally.

Abstract

Purpose: Although the decision of which ventilation strategy to adopt in COVID-19 patients is crucial, yet the most appropriate means of carrying out this undertaking is not supported by strong evidence. We therefore described the organization of a province-level healthcare system during the occurrence of the COVID-19 epidemic and the 60-day outcomes of the hospitalized COVID-19 patients according to the respiratory strategy adopted given the limited available resources.

Patients and methods: All COVID-19 patients (26/02/2020-18/04/2020) in the Rimini Province of Italy were included in this population-based cohort study. The hospitalized patients were classified according to the maximum level of respiratory support: oxygen supplementation (Oxygen group), non-invasive ventilation (NIV-only group), invasive mechanical ventilation (IMV-only group), and IMV after an NIV trial (IMV-after-NIV group). Sixty-day mortality risk was estimated with a Cox proportional hazard analysis adjusted by age, sex, and administration of steroids, canakinumab, and tocilizumab.

Results: We identified a total of 1,424 symptomatic patients: 520 (36.5%) were hospitalized, while 904 (63.5%) were treated at home with no 60-day deaths. Based on the respiratory support, 408 (78.5%) were assigned to the Oxygen group, 46 (8.8%) to the NIV-only group, 25 (4.8%) to the IMV-after-NIV group, and 41 (7.9%) to the IMV-only group. There was no significant difference in the PaO₂/FiO₂ at IMV inception in the IMV-after-NIV and IMV-only groups (p=0.9). Overall 60-day mortality was 24.2% (Oxygen: 23.0%; NIV-only: 19.6%; IMV-after-NIV: 32.0%; IMV-only: 36.6%; p=0.165). Compared with the Oxygen group, the adjusted 60-day mortality risk significantly increased in the IMV-after-NIV (HR 2.776; p=0.024) and IMV-only groups (HR 2.966; p=0.001).

Conclusion: This study provided a population-based estimate of the impact of the COVID-19 outbreak in a severely affected Italian province. A similar 60-day mortality risk was found for patients undergoing immediate IMV and those intubated after an NIV trial with favorable outcomes after prolonged IMV.

Keywords: ARDS; COVID-19; mechanical ventilation; mortality; multidisciplinary team approach; noninvasive ventilation.