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Severity of respiratory failure at admission and in-hospital mortality in patients with COVID-19: a prospective observational multicentre study.
BMJ Open. 2020 10 10; 10(10):e043651.BO

Abstract

OBJECTIVES

COVID-19 causes lung parenchymal and endothelial damage that lead to hypoxic acute respiratory failure (hARF). The influence of hARF severity on patients' outcomes is still poorly understood.

DESIGN

Observational, prospective, multicentre study.

SETTING

Three academic hospitals in Milan (Italy) involving three respiratory high dependency units and three general wards.

PARTICIPANTS

Consecutive adult hospitalised patients with a virologically confirmed diagnosis of COVID-19. Patients aged <18 years or unable to provide informed consent were excluded.

INTERVENTIONS

Anthropometrical, clinical characteristics and blood biomarkers were assessed within the first 24 hours from admission. hARF was graded as follows: severe (partial pressure of oxygen to fraction of inspired oxygen ratio (PaO2/FiO2) <100 mm Hg); moderate (PaO2/FiO2 101-200 mm Hg); mild (PaO2/FiO2 201-300 mm Hg) and normal (PaO2/FiO2 >300 mm Hg).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the assessment of clinical characteristics and in-hospital mortality based on the severity of respiratory failure. Secondary outcomes were intubation rate and application of continuous positive airway pressure during hospital stay.

RESULTS

412 patients were enrolled (280 males, 68%). Median (IQR) age was 66 (55-76) years with a PaO2/FiO2 at admission of 262 (140-343) mm Hg. 50.2% had a cardiovascular disease. Prevalence of mild, moderate and severe hARF was 24.4%, 21.9% and 15.5%, respectively. In-hospital mortality proportionally increased with increasing impairment of gas exchange (p<0.001). The only independent risk factors for mortality were age ≥65 years (HR 3.41; 95% CI 2.00 to 5.78, p<0.0001), PaO2/FiO2 ratio ≤200 mm Hg (HR 3.57; 95% CI 2.20 to 5.77, p<0.0001) and respiratory failure at admission (HR 3.58; 95% CI 1.05 to 12.18, p=0.04).

CONCLUSIONS

A moderate-to-severe impairment in PaO2/FiO2 was independently associated with a threefold increase in risk of in-hospital mortality. Severity of respiratory failure is useful to identify patients at higher risk of mortality.

TRIAL REGISTRATION NUMBER

NCT04307459.

Authors+Show Affiliations

Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milano, Italy pierachille.santus@unimi.it. Division of Respiratory Diseases, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74-20157, Ospedale Luigi Sacco-Polo Universitario, Milano, Italy.Division of Respiratory Diseases, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74-20157, Ospedale Luigi Sacco-Polo Universitario, Milano, Italy.Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali. Via Padre Manzella, 4-07100, Università degli Studi di Sassari, Sassari, Italy.Department of Medicine and Rehabilitation, Division of Emergency Medicine, ASST Fatebenefratelli-Sacco, Piazzale Principessa Clotilde, 3-20121, Ospedale Fatebenefratelli e Oftalmico, Milano, Italy.Division of Internal Medicine -ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74-20157, Ospedale Luigi Sacco-Polo Universitario, Milano, Italy.Direzione Sanitaria Aziendale, Via G.B. Grassi 74-20157, ASST Fatebenefratelli Sacco, Milano, Lombardia, Italy.Division of Respiratory Diseases, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74-20157, Ospedale Luigi Sacco-Polo Universitario, Milano, Italy.Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milano, Italy. Division of Respiratory Diseases, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74-20157, Ospedale Luigi Sacco-Polo Universitario, Milano, Italy.Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milano, Italy. Division of Respiratory Diseases, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74-20157, Ospedale Luigi Sacco-Polo Universitario, Milano, Italy.Department of Health Bioscience-Respiratory Unit, Policlinico di San Donato, IRCCS-Via Rodolfo Morandi, 30-20097, San Donato Milanese, Università degli Studi di Milano, Milano, Italy.Division of Internal Medicine -ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74-20157, Ospedale Luigi Sacco-Polo Universitario, Milano, Italy.Department of Medicine and Rehabilitation, Division of Emergency Medicine, ASST Fatebenefratelli-Sacco, Piazzale Principessa Clotilde, 3-20121, Ospedale Fatebenefratelli e Oftalmico, Milano, Italy.Department of Health Bioscience-Respiratory Unit, Policlinico di San Donato, IRCCS-Via Rodolfo Morandi, 30-20097, San Donato Milanese, Università degli Studi di Milano, Milano, Italy.Dipartimento Medico, USC Pneumologia, USS Servizio di Pneumologia, Ospedale di Codogno, Azienda Socio Sanitaria Territoriale di Lodi, Lodi, Italy.Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali. Via Padre Manzella, 4-07100, Università degli Studi di Sassari, Sassari, Italy.

Pub Type(s)

Journal Article
Multicenter Study
Observational Study

Language

eng

PubMed ID

33040020

Citation

Santus, Pierachille, et al. "Severity of Respiratory Failure at Admission and In-hospital Mortality in Patients With COVID-19: a Prospective Observational Multicentre Study." BMJ Open, vol. 10, no. 10, 2020, pp. e043651.
Santus P, Radovanovic D, Saderi L, et al. Severity of respiratory failure at admission and in-hospital mortality in patients with COVID-19: a prospective observational multicentre study. BMJ Open. 2020;10(10):e043651.
Santus, P., Radovanovic, D., Saderi, L., Marino, P., Cogliati, C., De Filippis, G., Rizzi, M., Franceschi, E., Pini, S., Giuliani, F., Del Medico, M., Nucera, G., Valenti, V., Tursi, F., & Sotgiu, G. (2020). Severity of respiratory failure at admission and in-hospital mortality in patients with COVID-19: a prospective observational multicentre study. BMJ Open, 10(10), e043651. https://doi.org/10.1136/bmjopen-2020-043651
Santus P, et al. Severity of Respiratory Failure at Admission and In-hospital Mortality in Patients With COVID-19: a Prospective Observational Multicentre Study. BMJ Open. 2020 10 10;10(10):e043651. PubMed PMID: 33040020.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Severity of respiratory failure at admission and in-hospital mortality in patients with COVID-19: a prospective observational multicentre study. AU - Santus,Pierachille, AU - Radovanovic,Dejan, AU - Saderi,Laura, AU - Marino,Pietro, AU - Cogliati,Chiara, AU - De Filippis,Giuseppe, AU - Rizzi,Maurizio, AU - Franceschi,Elisa, AU - Pini,Stefano, AU - Giuliani,Fabio, AU - Del Medico,Marta, AU - Nucera,Gabriella, AU - Valenti,Vincenzo, AU - Tursi,Francesco, AU - Sotgiu,Giovanni, Y1 - 2020/10/10/ PY - 2020/10/11/entrez PY - 2020/10/12/pubmed PY - 2020/10/30/medline KW - COVID-19 KW - respiratory infections KW - respiratory medicine (see thoracic medicine) KW - respiratory physiology KW - virology SP - e043651 EP - e043651 JF - BMJ open JO - BMJ Open VL - 10 IS - 10 N2 - OBJECTIVES: COVID-19 causes lung parenchymal and endothelial damage that lead to hypoxic acute respiratory failure (hARF). The influence of hARF severity on patients' outcomes is still poorly understood. DESIGN: Observational, prospective, multicentre study. SETTING: Three academic hospitals in Milan (Italy) involving three respiratory high dependency units and three general wards. PARTICIPANTS: Consecutive adult hospitalised patients with a virologically confirmed diagnosis of COVID-19. Patients aged <18 years or unable to provide informed consent were excluded. INTERVENTIONS: Anthropometrical, clinical characteristics and blood biomarkers were assessed within the first 24 hours from admission. hARF was graded as follows: severe (partial pressure of oxygen to fraction of inspired oxygen ratio (PaO2/FiO2) <100 mm Hg); moderate (PaO2/FiO2 101-200 mm Hg); mild (PaO2/FiO2 201-300 mm Hg) and normal (PaO2/FiO2 >300 mm Hg). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the assessment of clinical characteristics and in-hospital mortality based on the severity of respiratory failure. Secondary outcomes were intubation rate and application of continuous positive airway pressure during hospital stay. RESULTS: 412 patients were enrolled (280 males, 68%). Median (IQR) age was 66 (55-76) years with a PaO2/FiO2 at admission of 262 (140-343) mm Hg. 50.2% had a cardiovascular disease. Prevalence of mild, moderate and severe hARF was 24.4%, 21.9% and 15.5%, respectively. In-hospital mortality proportionally increased with increasing impairment of gas exchange (p<0.001). The only independent risk factors for mortality were age ≥65 years (HR 3.41; 95% CI 2.00 to 5.78, p<0.0001), PaO2/FiO2 ratio ≤200 mm Hg (HR 3.57; 95% CI 2.20 to 5.77, p<0.0001) and respiratory failure at admission (HR 3.58; 95% CI 1.05 to 12.18, p=0.04). CONCLUSIONS: A moderate-to-severe impairment in PaO2/FiO2 was independently associated with a threefold increase in risk of in-hospital mortality. Severity of respiratory failure is useful to identify patients at higher risk of mortality. TRIAL REGISTRATION NUMBER: NCT04307459. SN - 2044-6055 UR - https://www.unboundmedicine.com/medline/citation/33040020/Severity_of_respiratory_failure_at_admission_and_in_hospital_mortality_in_patients_with_COVID_19:_a_prospective_observational_multicentre_study_ L2 - https://bmjopen.bmj.com/lookup/pmidlookup?view=long&amp;pmid=33040020 DB - PRIME DP - Unbound Medicine ER -