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ABSTRACT
Introduction: The use of mechanical ventilation associated with acute hypoxemic respiratory failure, the most common complication in critically ill COVID-19 patients, defines a high risk population that requires specific consideration of outcomes and treatment practices.
Areas covered: This review evaluates existing information about mortality rates and effectiveness of antiviral, immune-modulating, and anticoagulation treatments in COVID-19 patients who received mechanical ventilation. The mortality rate and follow-up periods in patients receiving mechanical ventilation ranged widely. Antivirals, including remdesivir and convalescent plasma, have shown no definitive mortality benefit in this population despite positive results in other COVID-19 patients. Dexamethasone was associated with an absolute reduction in 28-day mortality by 12.3% (95% CI, 6.3 to 17.6), after adjusting for age. Reduced mortality has been demonstrated with tocilizumab use alongside corticosteroids. Evidence is inconclusive for therapeutic anticoagulation, and further studies are needed to determine the comparative benefit of prophylactic anticoagulation.
Expert opinion: Significant variation and high mortality rates in mechanically ventilated patients necessitate more standardized outcome measurements, increased consideration of risk factors to reduce intubation, and improved treatment practices. Anticoagulation and dexamethasone should be incorporated in the treatment of patients receiving invasive mechanical ventilation, while more rigorous studies are required for other potential treatments.
Abbreviations
| ARDS=acute respiratory distress syndrome | = | |
| HFNC=high-flow nasal cannula | = | |
| ICU=intensive care unit | = | |
| IMV=invasive mechanical ventilation | = | |
| NIH=National Institutes of Health | = | |
| NIPPV=non-invasive positive-pressure ventilation | = | |
| NIV=non-invasive ventilation | = | |
| UK=United Kingdom | = | |
| USA/US=United States of America | = | |
| WHO=World Health Organization | = |
Article highlights
Patients with COVID-19 who develop acute respiratory distress syndrome (ARDS) and require mechanical ventilation have high mortality rates.
Despite indications for use in less severe COVID-19, antivirals have not demonstrated conclusive mortality benefits in mechanically ventilated patients.
Anticoagulation and dexamethasone treatment are associated with reduced mortality among patients receiving invasive mechanical ventilation.
Convalescent plasma, other immune-modulators like tocilizumab and therapeutic plasma exchange, and thrombolysis are promising but require more rigorous evidence to support clinical use.
Declaration of interest
The author(s) have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
Reviewer disclosures
Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.