Dedicated, impassioned, and exhausted clinicians the world over are collaborating to report the emerging profile of the coronavirus disease 2019 (COVID-19) pandemic. The unparalleled need for intensive care during this period challenges clinicians to bring their best efforts to the bedside, while advising health care leaders on the optimal management of resources to deliver that care in each jurisdiction. A renewed sense of community is avowed among critical care clinicians who share their early observations through traditional and social media, such that learnings from one group of patients can inform the care of the next.

The multicenter report by Grasselli and colleagues in JAMA provides sobering evidence about the burden of critical illness associated with COVID-19 in Lombardy, Italy.¹ Of the 1591 predominantly older, male patients with comorbid conditions admitted to the intensive care units (ICUs) of 72 hospitals from February 20 to March 18, 2020, the majority had moderate to severe acute respiratory distress syndrome (ARDS). Overall, of the 88% of patients who underwent endotracheal intubation and mechanical ventilation, the median level of positive end-expiratory pressure (PEEP) was 14 cm H₂O. In this cohort, 11% received noninvasive ventilation, exposure to which may have been even more extensive outside the ICU, in original or repurposed high-dependency units for patients with COVID-19, and 27% received early prone ventilation, reflecting the growing reports of using this strategy. By the end of the follow-up period, 26% of patients had died while 58% remained in the ICU. As reported in other series, older patients appeared to have the worst outcomes.¹

The demographic characteristics of the Italian population in this study differ in some respects from earlier experiences in China. Both countries reported male sex, older age, and hypertension as risk factors for severe COVID-19 disease. However, more patients in this series received invasive ventilation, which may reflect inherent differences in clinical presentation, ICU admission criteria, or approaches to management. The massive and acute strain on normally limited ICU resources is striking. Over a period of 28 days, close to 1600 patients, most of whom required ventilatory support, were admitted to 72 Italian ICUs, an average of 22 patients per ICU. Moreover, the median ICU length of stay was 9 days. This demand far exceeds the capacity of even the best-resourced health care system and points to the potential morbidity and mortality awaiting in less-resourced areas.