Background

Although COVID-19 has greatly affected many low-income and middle-income countries, detailed information about patients admitted to the intensive care unit (ICU) is still scarce. Our aim was to examine ventilation characteristics and outcomes in invasively ventilated patients with COVID-19 in Argentina, an upper middle-income country.

Methods

In this prospective, multicentre cohort study (SATICOVID), we enrolled patients aged 18 years or older with RT-PCR-confirmed COVID-19 who were on invasive mechanical ventilation and admitted to one of 63 ICUs in Argentina. Patient demographics and clinical, laboratory, and general management variables were collected on day 1 (ICU admission); physiological respiratory and ventilation variables were collected on days 1, 3, and 7. The primary outcome was all-cause in-hospital mortality. All patients were followed until death in hospital or hospital discharge, whichever occurred first. Secondary outcomes were ICU mortality, identification of independent predictors of mortality, duration of invasive mechanical ventilation, and patterns of change in physiological respiratory and mechanical ventilation variables. The study is registered with ClinicalTrials.gov, NCT04611269, and is complete.

Findings

Between March 20, 2020, and Oct 31, 2020, we enrolled 1909 invasively ventilated patients with COVID-19, with a median age of 62 years [IQR 52–70]. 1294 (67·8%) were men, hypertension and obesity were the main comorbidities, and 939 (49·2%) patients required vasopressors. Lung-protective ventilation was widely used and median duration of ventilation was 13 days (IQR 7–22). Median tidal volume was 6·1 mL/kg predicted bodyweight (IQR 6·0–7·0) on day 1, and the value increased significantly up to day 7; positive end-expiratory pressure was 10 cm H₂O (8–12) on day 1, with a slight but significant decrease to day 7. Ratio of partial pressure of arterial oxygen (PaO₂) to fractional inspired oxygen (FiO₂) was 160 (IQR 111–218), respiratory system compliance 36 mL/cm H₂O (29–44), driving pressure 12 cm H₂O (10–14), and FiO₂ 0·60 (0·45–0·80) on day 1. Acute respiratory distress syndrome developed in 1672 (87·6%) of patients; 1176 (61·6%) received prone positioning. In-hospital mortality was 57·7% (1101/1909 patients) and ICU mortality was 57·0% (1088/1909 patients); 462 (43·8%) patients died of refractory hypoxaemia, frequently overlapping with septic shock (n=174). Cox regression identified age (hazard ratio 1·02 [95% CI 1·01–1·03]), Charlson score (1·16 [1·11–1·23]), endotracheal intubation outside of the ICU (ie, before ICU admission; 1·37 [1·10–1·71]), vasopressor use on day 1 (1·29 [1·07–1·55]), D-dimer concentration (1·02 [1·01–1·03]), PaO₂/FiO₂ on day 1 (0·998 [0·997–0·999]), arterial pH on day 1 (1·01 [1·00–1·01]), driving pressure on day 1 (1·05 [1·03–1·08]), acute kidney injury (1·66 [1·36–2·03]), and month of admission (1·10 [1·03–1·18]) as independent predictors of mortality.

Interpretation

In patients with COVID-19 who required invasive mechanical ventilation, lung-protective ventilation was widely used but mortality was high. Predictors of mortality in our study broadly agreed with those identified in studies of invasively ventilated patients in high-income countries. The sustained burden of COVID-19 on scarce health-care personnel might have contributed to high mortality over the course of our study in Argentina. These data might help to identify points for improvement in the management of patients in middle-income countries and elsewhere.

Funding

None.

Translation

For the Spanish translation of the Summary see Supplementary Materials section.

中文翻译：

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阿根廷 COVID-19 有创通气患者 (SATICOVID) 的临床特征和结果：一项前瞻性、多中心队列研究

背景

尽管 COVID-19 对许多低收入和中等收入国家产生了很大影响，但关于入住重症监护病房 (ICU) 的患者的详细信息仍然很少。我们的目的是检查阿根廷这个中上收入国家的 COVID-19 有创通气患者的通气特征和结果。

方法

在这项前瞻性、多中心队列研究 (SATICOVID) 中，我们招募了年龄在 18 岁或以上且经 RT-PCR 确诊的 COVID-19 患者，这些患者正在接受有创机械通气并入住阿根廷 63 家 ICU 之一。在第 1 天（入住 ICU）收集患者人口统计学和临床​​、实验室和一般管理变量；在第 1、3 和 7 天收集生理呼吸和通气变量。主要结果是全因住院死亡率。随访所有患者直至住院或出院，以先发生者为准。次要结局是 ICU 死亡率、死亡率的独立预测因素的确定、有创机械通气的持续时间以及生理呼吸和机械通气变量的变化模式。

发现

2020 年 3 月 20 日至 2020 年 10 月 31 日期间，我们招募了 1909 名 COVID-19 有创通气患者，中位年龄为 62 岁 [IQR 52-70]。1294（67·8%）名男性，高血压和肥胖是主要合并症，939（49·2%）名患者需要血管加压药。肺保护性通气被广泛使用，通气的中位持续时间为 13 天（IQR 7-22）。中位潮气量在第 1 天为 6·1 mL/kg 预测体重（IQR 6·0–7·0），该值在第 7 天显着增加；第 1 天的呼气末正压为 10 cm H ₂ O (8-12)，到第 7 天略有但显着降低。动脉氧分压 (PaO ₂ ) 与吸入氧分压 (FiO _{2) 之比}) 为 160 (IQR 111–218)，呼吸系统顺应性 36 mL/cm H ₂ O (29–44)，驱动压力 12 cm H ₂ O (10–14) 和 FiO ₂ 0·60 (0·45– 0·80) 第 1 天。1672 (87·6%) 名患者出现急性呼吸窘迫综合征；1176 (61·6%) 人接受俯卧位。住院死亡率为 57·7%（1101/1909 例患者），ICU 死亡率为 57·0%（1088/1909 例患者）；462 (43·8%) 名患者死于难治性低氧血症，经常与感染性休克重叠 (n=174)。Cox 回归确定了年龄（风险比 1·02 [95% CI 1·01-1·03]）、Charlson 评分（1·16 [1·11-1·23]）、ICU 外的气管插管（即， ICU 入住前；1·37 [1·10–1·71])，第 1 天使用血管加压药 (1·29 [1·07-1·55])，D-二聚体浓度 (1·02 [1·01] –1·03]), PaO ₂/FiO ₂第 1 天 (0·998 [0·997–0·999])，第 1 天动脉 pH 值 (1·01 [1·00–1·01])，第 1 天驱动压 (1·05 [1·03-1·08]）、急性肾损伤（1·66 [1·36-2·03]）和入院月份（1·10 [1·03-1·18]）作为独立预测因素死亡率。

解释

在需要有创机械通气的 COVID-19 患者中，肺保护性通气被广泛使用，但死亡率很高。我们研究中的死亡率预测因子与高收入国家有创通气患者研究中确定的预测因子大体一致。在我们在阿根廷的研究过程中，COVID-19 对稀缺卫生保健人员的持续负担可能导致了高死亡率。这些数据可能有助于确定在中等收入国家和其他地方改善患者管理的要点。

资金

没有任何。

翻译

有关摘要的西班牙语翻译，请参阅补充材料部分。