key: cord-1015943-m697e71g
authors: White, Seth; Zubair, Ayla; Vallumselta, Nishanth; Spiezio, Nicholas; Valencia, Laura Rodriguez; Wlody, David
title: Early experiences and outcomes using non-invasive ventilation during the 2020 surge in New York City at a Covid-19 designated institution
date: 2021-03-12
journal: J Clin Anesth
DOI: 10.1016/j.jclinane.2021.110246
sha: 7ac9ac4b2fb9806cf1933fa9fd1a5591cd244d7d
doc_id: 1015943
cord_uid: m697e71g

nan

Early experiences and outcomes using non-invasive ventilation during the 2020 surge in New York City at a Covid-19 designated institution To the editor:

As an early epicenter of the novel coronavirus pandemic Covid-19, New York City hospitals faced an historic surge in cases in March 2020. Some early projections put the potential need for ventilators in New York state at greater than 30,000 [1] . Although the eventual number used was far lower, clinicians in early epicenters were forced to treat large numbers of patients with limited data and experience.

SUNY Downstate Medical Center, a 342-bed tertiary referral center, was designated a "Covid-only" hospital on March 28th 2020 by Governor Cuomo [2] , and experienced a considerable early volume of critically ill patients with Covid-19. Despite the initial preference for early intubation, practical concerns about the limited availability of ventilators necessitated the widespread use of non-invasive ventilation (NIV) -primarily biphasic positive airway pressure (BiPAP) and highflow nasal cannulae (HFNC).

The respiratory department went from an average of 34 patients on NIV per month to 120 patients in the month of April alone, whilst length of therapy on NIV almost doubled from approximately 3.5 days to 6 days per patient. The workload increased from 120 days of therapy to 770 days, whereas staffing did not rise in proportion to the demand.

Even with the validity of NIV in Covid-19 now well established [3] [4] [5] , it is worth evaluating outcomes of patients during the initial state of emergency when resources and staff were being stretched beyond capacity. There were few data available on Covid-19 infection available at the time. Most patients were treated with a combination of hydroxychloroquine and azithromycin, which has since been proven ineffective [6] .

After obtaining IRB approval (IRB 1609410) physical records from the respiratory department at SUNY Downstate Medical Center were reviewed. Patients above the age of 18 years admitted during the period March 1st to April 30th 2020, started on NIV with a PCR confirmed diagnosis of SARS-CoV-2 were identified. Cases were then confirmed by electronic medical record (EMR) review with two separate reviewers collecting data on each case. Cases where reviewers could not agree on therapy type or dates were excluded. In the final analysis, 102 Covid-19 confirmed patients were included. Data was analyzed in SPSS with chisquared test for nominal data and independent t-tests on continuous data.

Of the 102 patients, 69 (67%) were started initially on BiPAP, 33 (33%) on HFNC. The patient population was elderly across the three groups, with a mean age of 66 years. 92 (90.2%) all patients had at least one listed co-morbid condition, and 64 (62.7%) had at least two (see Table 1 )

Mortality was lower in the HFNC group (54.5%) compared to the BiPAP (70.7%) group, but this difference did not reach statistical significance (p = 0.101). Patients who were not intubated were more likely to survive than those who were intubated (60% vs 81% p = 0.044). Time to intubation did not vary significantly between groups. Switching between therapies was common: 46% of patients switched to at least one other form of NIV with 19.6% switching therapy two or more times. Average length of therapy before change of therapy was 4 four days.

Most deaths occurred on NIV without intubation (only 35.8% of deaths occurred on mechanical ventilation). 61% of patients who died had either do not resuscitate (DNR) or do not intubate (DNI) advance directives, or both.

NIV modalities appeared broadly similar in their efficacy, and differences in co-morbidities and outcomes were comparable. Mortality was high overall. The data demonstrates the scale of the challenge of Covid-19 early in the pandemic in an elderly cohort with many comorbidities.

The deaths without intubation suggested by the data highlights the delicate balance of starting NIV versus intubation at the height of the crisis in New York when resources were limited. Sudden deterioration is a known feature of Covid-19 infection, and some patients may have clinically declined unobserved on NIV. Temporary improvised isolation rooms and proportionally low staffing likely contributed to the danger. Ultimately, even though there was never a ventilator shortage, the following medications essential to intubation and intensive care were out of stock during various points in April 2020 at our institution: fentanyl, propofol, ketamine, dexmedetomidine, and cisatracurium. Considering these shortages, starting invasive ventilation was not always an easy decision. Nonetheless, our data suggests that starting patients on NIV is reasonable during a critical surge in system demand.

None.

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