The time lapse between starting noninvasive ventilation (NIV) and venovenous extracorporeal membrane oxygenation (VV-ECMO) is associated with 90-day mortality in patients critically ill with COVID-19-related acute respiratory distress syndrome (ARDS), according to study findings published in BMC Pulmonary Medicine.

Some recent studies report worsening outcomes with VV-ECMO parallel with increased use of NIV. Therefore, investigators sought to assess how the time lapse between initiation of NIV and VV-ECMO initiation affects outcomes in patients critically ill with COVID-19-associated ARDS.

This prospective observational study was conducted in an intensive care unit (ICU) of a Hospital Universitari de Bellvitge in Barcelona, Spain. The investigators included 72 consecutive patients (mean [SD] age, 53 [8] years; 19.5% female) between March 2020 and January 2022 who were critically ill with COVID-19-related ARDS and received noninvasive respiratory support or invasive mechanical ventilation and eventually received VV-ECMO. COVID-19 was verified by reverse transcriptase-polymerase chain reaction testing.

Of the 72 patients presenting to the ICU with SARS-CoV-2 who ultimately received VV-ECMO, 70 patients underwent invasive mechanical ventilation and 2 patients underwent only NIV.

[T]he time spent between initiation of NIV support and VV-ECMO (together with age and lactate) appeared to be a better predictor of mortality than the time between intubation and VV-ECMO.

The investigators found 37 patients (52%) were still alive 90 days after initiating VV-ECMO. The 2 patients who underwent only NIV did not survive. At VV-ECMO initiation, age, lactate levels, and days from initiation of NIV were significantly associated with 90-day mortality in multivariable logistic regression (odds ratio [OR]for age, 1.06; 95% CI 1.01-1.12; P =.02); (OR for lactate, 1.27; 95% CI, 1.11-1.44; P =.01); (OR for days from initiation of NIV, 1.03; 95% CI, 1.01-1.05; P =.04).

In linear regression, time from initiation of NIV to VV-ECMO was a median of 9 days (interquartile range [IQR], 5-15 days; P =.07). Time from intubation to VV-ECMO was a median of 4 days (IQR, 2-9 days; P =.60).  Time from NIV to endotracheal intubation was a median of 3 days (IQR, 0-6 days; P =.07). Patients who survived were younger and had a shorter time lapse from NIV to VV-ECMO. Patients who did not survive vs those who did had a higher but statistically nonsignificant proportion of comorbid hypertension (46% vs 35%), diabetes (26% vs 19%) and chronic pulmonary disease (14% vs 0%). Significantly, those who did not survive had a lower D-dimer at ECMO initiation.

Study limitations include the duration of invasive ventilation as a confounding variable and underpowered sample size.

“In our small cohort of VV-ECMO patients with COVID-19 associated ARDS, the time spent between initiation of NIV support and VV-ECMO (together with age and lactate) appeared to be a better predictor of mortality than the time between intubation and VV-ECMO,” the investigators concluded. The study authors wrote, “We suggest, based on our findings, that the time spent between NIV support and initiation of VV-ECMO should be considered and evaluated as an interesting clinical parameter to be included in the mortality prediction scores for VV-ECMO.”

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