Failure of First Transition to Pressure Support Ventilation After Spontaneous Awakening Trials in Hypoxemic Respiratory Failure: Influence of COVID-19

Joaquin Pérez; Matías Accoce; Javier H Dorado; Daniela I Gilgado; Emiliano Navarro; Gimena P Cardoso; Irene Telias; Pablo O Rodriguez; Laurent Brochard

doi:10.1097/CCE.0000000000000968

Failure of First Transition to Pressure Support Ventilation After Spontaneous Awakening Trials in Hypoxemic Respiratory Failure: Influence of COVID-19

Crit Care Explor. 2023 Aug 25;5(9):e0968. doi: 10.1097/CCE.0000000000000968. eCollection 2023 Sep.

Authors

Joaquin Pérez^{1

2}, Matías Accoce^{1

3

4}, Javier H Dorado¹, Daniela I Gilgado^{1

2}, Emiliano Navarro⁵, Gimena P Cardoso^{1

6}, Irene Telias^{7

8

9}, Pablo O Rodriguez^{10

11}, Laurent Brochard^{7

8}

Affiliations

¹ Intensive Care Unit, Sanatorio Anchorena, San Martín, Buenos Aires, Argentina.
² Intensive Care Unit, Hospital Carlos G. Durand, Ciudad Autónoma de Buenos Aires, Argentina.
³ Intensive Care Unit, Hospital de Quemados "Dr. Arturo Humberto Illia," Ciudad Autónoma de Buenos Aires, Argentina.
⁴ Faculta de Medicina y Ciencias de la Salud, Universidad Abierta Interamericana, Ciudad Autónoma de Buenos Aires, Argentina.
⁵ Respiratory and physical therapy department, Centro del Parque, Ciudad Autónoma de Buenos Aires, Argentina.
⁶ Intensive Care Unit, Hospital Donación Francisco Santojanni, Ciudad Autónoma de Buenos Aires, Argentina.
⁷ Department of Critical Care, Keenan Research Center, Li Ka Shing Institute, St Michael's Hospital, Toronto, Ontario, Canada.
⁸ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.
⁹ Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada.
¹⁰ Intensive Care Unit, Hospital Universitario Sede Pombo (Instituto Universitario CEMIC, Centro de Educación Médica e Investigaciones Clínicas), Ciudad Autónoma de Buenos Aires, Argentina.
¹¹ Pneumonology section, CEMIC, Ciudad Autónoma de Buenos Aires, Argentina.

Abstract

Objectives: To describe the rate of failure of the first transition to pressure support ventilation (PSV) after systematic spontaneous awakening trials (SATs) in patients with acute hypoxemic respiratory failure (AHRF) and to assess whether the failure is higher in COVID-19 compared with AHRF of other etiologies. To determine predictors and potential association of failure with outcomes.

Design: Retrospective cohort study.

Setting: Twenty-eight-bedded medical-surgical ICU in a private hospital (Argentina).

Patients: Subjects with arterial pressure of oxygen (AHRF to Fio₂ [Pao₂/Fio₂] < 300 mm Hg) of different etiologies under controlled mechanical ventilation (MV).

Interventions: None.

Measurements and main results: We collected data during controlled ventilation within 24 hours before SAT followed by the first PSV transition. Failure was defined as the need to return to fully controlled MV within 3 calendar days of PSV start. A total of 274 patients with AHRF (189 COVID-19 and 85 non-COVID-19) were included. The failure occurred in 120 of 274 subjects (43.7%) and was higher in COVID-19 versus non-COVID-19 (49.7% and 30.5%; p = 0.003). COVID-19 diagnosis (odds ratio [OR]: 2.22; 95% CI [1.15-4.43]; p = 0.020), previous neuromuscular blockers (OR: 2.16; 95% CI [1.15-4.11]; p = 0.017) and higher fentanyl dose (OR: 1.29; 95% CI [1.05-1.60]; p = 0.018) increased the failure chances. Higher BMI (OR: 0.95; 95% CI [0.91-0.99]; p = 0.029), Pao₂/Fio₂ (OR: 0.87; 95% CI [0.78-0.97]; p = 0.017), and pH (OR: 0.61; 95% CI [0.38-0.96]; p = 0.035) were protective. Failure groups had higher 60-day ventilator dependence (p < 0.001), MV duration (p < 0.0001), and ICU stay (p = 0.001). Patients who failed had higher mortality in COVID-19 group (p < 0.001) but not in the non-COVID-19 (p = 0.083).

Conclusions: In patients with AHRF of different etiologies, the failure of the first PSV attempt was 43.7%, and at a higher rate in COVID-19. Independent risk factors included COVID-19 diagnosis, fentanyl dose, previous neuromuscular blockers, acidosis and hypoxemia preceding SAT, whereas higher BMI was protective. Failure was associated with worse outcomes.

Keywords: acute respiratory distress syndrome; assisted ventilation; mechanical ventilation; respiratory insufficiency; sedatives.