COVID-19 respiratory support outside the ICU's doors. An observational study for a new operative strategy

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Elena Bignami
Valentina Bellini
Giada Maspero
Barbara Pifferi
Leonardo Fortunati Rossi
Andrea Ticinesi
Michelangelo Craca
Tiziana Meschi
Marco Baciarello


COVID-19 – Hypoxia – HFNC – NIV - ICU


Background and aim: During the first wave of the Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV-2) pandemic, we faced a massive clinical and organizational challenge having to manage critically ill patients outside the Intensive Care Unit (ICU). This was due to the significant imbalance between ICU bed availability and the number of patients presenting Acute Hypoxemic Respiratory Failure caused by SARS-CoV-2-related interstitial pneumonia. We therefore needed to perform Non-Invasive Ventilation (NIV) in non-intensive wards to assist these patients and relieve pressure on the ICUs and subsequently implemented a new organizational and clinical model. This study was aimed at evaluating its effectiveness and feasibility.

Methods: We recorded the anamnestic, clinical and biochemical data of patients undergoing non-invasive mechanical ventilation while hospitalized in non-intensive CoronaVirus Disease 19 (COVID-19) wards. Data were registered on admission, during anesthesiologist counseling, and when NIV was started and suspended. We retrospectively registered the available results from routine arterial blood gas and laboratory analyses for each time point.

Results: We retrospectively enrolled 231 patients. Based on our criteria, we identified 46 patients as NIV responders, representing 19.9% ​​of the general study population and 29.3% of the patients that spent their entire hospital stay in non-ICU wards. Overall mortality was 56.2%, with no significant differences between patients in non-intensive wards (57.3%) and those later admitted to the ICU (54%)

Conclusions: NIV is safe and manageable in an emergency situation and could become part of an integrated clinical and organizational model.


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1. Coronavirus disease 2019 (COVID-19) Situation Report – 67. .
2. Miller DC, Beamer P, Billheimer D, Subbian V, Sorooshian A, Campbell BS et al. Aerosol risk with noninvasive respiratory support in patients with COVID-19. J. Am. Coll. Emerg. Physicians Open 2020; 1: 521–526.
3. Antonelli M, Conti G, Esquinas A, Montini L, Maggiore SM, Bello G et al. A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome. Crit. Care Med. 2007; 35: 18–25.
4. Villarreal-Fernandez E, Patel R, Golamari R, Khalid M, DeWaters A, Haouzi P. A plea for avoiding systematic intubation in severely hypoxemic patients with COVID-19-associated respiratory failure. Crit. Care 2020; 24: 337.
5. Paternoster G, Sartini C, Pennacchio E, Lisanti F, Landoni G, Cabrini L. Awake pronation with helmet continuous positive airway pressure for COVID-19 acute respiratory distress syndrome patients outside the ICU: A case series. Med. Intensiva 2020; : S0210569120302734.
6. Demoule A, Chevret S, Carlucci A, Kouatchet A, Jaber S, Meziani F, et al. oVNI Study Group, REVA Network (Research Network in Mechanical Ventilation). Changing use of noninvasive ventilation in critically ill patients: trends over 15 years in francophone countries. Intensive Care Med. 2016; 42: 82–92.
7. Alviset S, Riller Q, Aboab J, Dilworth K, Billy P-A, Lombardi Y, et al. Continuous Positive Airway Pressure (CPAP) face-mask ventilation is an easy and cheap option to manage a massive influx of patients presenting acute respiratory failure during the SARS-CoV-2 outbreak: A retrospective cohort study. PloS One 2020; 15: e0240645.
8. Brusasco C, Corradi F, Di Domenico A, Raggi F, Timossi G, Santori G, et al. Continuous positive airway pressure in Covid-19 patients with moderate-to-severe respiratory failure. Eur. Respir. J. 2020; : 2002524.
9. Oranger M, Gonzalez-Bermejo J, Dacosta-Noble P, Llontop C, Guerder A, Trosini-Desert V et al. Continuous positive airway pressure to avoid intubation in SARS-CoV-2 pneumonia: a two-period retrospective case-control study. Eur. Respir. J. 2020; 56: 2001692.
10. Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. 2020; : 1–34.
11. Bellani G, Laffey JG, Pham T, Madotto F, Fan E, Brochard L et al. Noninvasive Ventilation of Patients with Acute Respiratory Distress Syndrome. Insights from the LUNG SAFE Study. Am. J. Respir. Crit. Care Med. 2017; 195: 67–77.
12. Alraddadi BM, Qushmaq I, Al-Hameed FM, Mandourah Y, Almekhlafi GA, Jose J et al, Saudi Critical Care Trials Group. Noninvasive ventilation in critically ill patients with the Middle East respiratory syndrome. Influenza Other Respir. Viruses 2019; 13: 382–390.
13. Guan L, Zhou L, Le Grange JM, Zheng Z, Chen R. Non-invasive ventilation in the treatment of early hypoxemic respiratory failure caused by COVID-19: considering nasal CPAP as the first choice. Crit. Care 2020; 24: 333.
14. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet Elsevier; 2020; 395: 497–506.
15. Longhini F, Bruni A, Garofalo E, Navalesi P, Grasselli G, Cosentini R et al. Helmet continuous positive airway pressure and prone positioning: A proposal for an early management of COVID-19 patients. Pulmonology 2020; 26: 186–191.
16. Lucchini A, Giani M, Isgrò S, Rona R, Foti G. The “helmet bundle” in COVID-19 patients undergoing non invasive ventilation. Intensive Crit. Care Nurs. 2020; 58: 102859.
17. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China. JAMA 2020; 323: 1061.
18. Pagano A, Porta G, Bosso G, Allegorico E, Serra C, Dello Vicario F et al. Non-invasive CPAP in mild and moderate ARDS secondary to SARS-CoV-2. Respir. Physiol. Neurobiol. 2020; 280: 103489.
19. Raoof S, Nava S, Carpati C, Hill NS. High-Flow, Noninvasive Ventilation and Awake (Nonintubation) Proning in Patients With Coronavirus Disease 2019 With Respiratory Failure. Chest 2020; 158: 1992–2002.
20. Duca A, Memaj I, Zanardi F, Preti C, Alesi A, Della Bella L et al. Severity of respiratory failure and outcome of patients needing a ventilatory support in the Emergency Department during Italian novel coronavirus SARS-CoV2 outbreak: Preliminary data on the role of Helmet CPAP and Non-Invasive Positive Pressure Ventilation. EClinicalMedicine 2020; 24: 100419.
21. Lynch JB, Davitkov P, Anderson DJ, Bhimraj A, Cheng VC-C, Guzman-Cottrill J, et al. Infectious Diseases Society of America Guidelines on Infection Prevention for Health Care Personnel Caring for Patients with Suspected or Known COVID-19. Clin. Infect. Dis. Off. Publ. Infect. Dis. Soc. Am. (Internet) 2020 (cited 2021 Jan 28); Available from:
22. Fowler RA, Guest CB, Lapinsky SE, Sibbald WJ, Louie M, Tang P et al. Transmission of severe acute respiratory syndrome during intubation and mechanical ventilation. Am. J. Respir. Crit. Care Med. 2004; 169: 1198–1202.
23. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PloS One 2012; 7: e35797.
24. Privitera D, Angaroni L, Capsoni N, Forni E, Pierotti F, Vincenti F et al. Flowchart for non-invasive ventilation support in COVID-19 patients from a northern Italy Emergency Department. Intern. Emerg. Med. 2020; 15: 767–771.
25. Montrief T, Ramzy M, Long B, Gottlieb M, Hercz D. COVID-19 respiratory support in the emergency department setting. Am. J. Emerg. Med. 2020; 38: 2160–2168.
26. Winck JC, Ambrosino N. COVID-19 pandemic and non invasive respiratory management: Every Goliath needs a David. An evidence based evaluation of problems. Pulmonology 2020; 26: 213–220.27. Nielsen Jeschke K, Bonnesen B, Hansen EF, Jensen J-US, Lapperre TS, Weinreich UM et al. Guideline for the management of COVID-19 patients during hospital admission in a non-intensive care setting. Eur. Clin. Respir. J. 2020; 7: 1761677.
28. Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur. Respir. J. 2017; 50: 1602426.
29. Chiumello D, Brochard L, Marini JJ, Slutsky AS, Mancebo J, Ranieri VM et al. Respiratory support in patients with acute respiratory distress syndrome: an expert opinion. Crit. Care Lond. Engl. 2017; 21: 240.
30. Nicolini A, Ferraioli G, Ferrari-Bravo M, Barlascini C, Santo M, Ferrera L. Early non-invasive ventilation treatment for respiratory failure due to severe community-acquired pneumonia: Pneumonia and non-invasive ventilation. Clin. Respir. J. 2016; 10: 98–103.
31. Nava S, Hill N. Non-invasive ventilation in acute respiratory failure. 2009; 374: 11.
32. Imber DA, Pirrone M, Zhang C, Fisher DF, Kacmarek RM, Berra L. Respiratory Management of Perioperative Obese Patients. Respir. Care Respiratory Care; 2016; 61: 1681–1692.
33. Vetrugno L, Baciarello M, Bignami E, Bonetti A, Saturno F, Orso D et al. The “pandemic” increase in lung ultrasound use in response to Covid-19: can we complement computed tomography findings? A narrative review. Ultrasound J. (Internet) 2020 (cited 2021 Feb 9); 12Available from:
34. Faraone A, Beltrame C, Crociani A, Carrai P, Lovicu E, Filetti S et al. Effectiveness and safety of noninvasive positive pressure ventilation in the treatment of COVID-19-associated acute hypoxemic respiratory failure: a single center, non-ICU setting experience. Intern. Emerg. Med. (Internet) 2020 (cited 2021 Jan 28); Available from:
35. Cerceo E, Fraimow H. Lessons Learned From the Front Line: Outcomes of Noninvasive Ventilation for Coronavirus Disease 2019 Pneumonia in China. 2020; 48: 3.
36. Nouvenne A, Zani MD, Milanese G, Parise A, Baciarello M, Bignami EG et al. Lung Ultrasound in COVID-19 Pneumonia: Correlations with Chest CT on Hospital admission. Respiration 2020; : 1–8.
37. Ferrari D, Milic J, Tonelli R, Ghinelli F, Meschiari M, Volpi S et al. Machine learning in predicting respiratory failure in patients with COVID-19 pneumonia-Challenges, strengths, and opportunities in a global health emergency. PloS One 2020; 15: e0239172.

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