Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
Critical Care
Published in: Critical Care 1/2020

Open Access 01-12-2020 | Acute Respiratory Distress-Syndrome | Research

Respiratory physiology of COVID-19-induced respiratory failure compared to ARDS of other etiologies

Authors: Domenico Luca Grieco, Filippo Bongiovanni, Lu Chen, Luca S. Menga, Salvatore Lucio Cutuli, Gabriele Pintaudi, Simone Carelli, Teresa Michi, Flava Torrini, Gianmarco Lombardi, Gian Marco Anzellotti, Gennaro De Pascale, Andrea Urbani, Maria Grazia Bocci, Eloisa S. Tanzarella, Giuseppe Bello, Antonio M. Dell’Anna, Salvatore M. Maggiore, Laurent Brochard, Massimo Antonelli

Published in: Critical Care | Issue 1/2020

Login to get access

Abstract

Background

Whether respiratory physiology of COVID-19-induced respiratory failure is different from acute respiratory distress syndrome (ARDS) of other etiologies is unclear. We conducted a single-center study to describe respiratory mechanics and response to positive end-expiratory pressure (PEEP) in COVID-19 ARDS and to compare COVID-19 patients to matched-control subjects with ARDS from other causes.

Methods

Thirty consecutive COVID-19 patients admitted to an intensive care unit in Rome, Italy, and fulfilling moderate-to-severe ARDS criteria were enrolled within 24 h from endotracheal intubation. Gas exchange, respiratory mechanics, and ventilatory ratio were measured at PEEP of 15 and 5 cmH2O. A single-breath derecruitment maneuver was performed to assess recruitability. After 1:1 matching based on PaO2/FiO2, FiO2, PEEP, and tidal volume, COVID-19 patients were compared to subjects affected by ARDS of other etiologies who underwent the same procedures in a previous study.

Results

Thirty COVID-19 patients were successfully matched with 30 ARDS from other etiologies. At low PEEP, median [25th–75th percentiles] PaO2/FiO2 in the two groups was 119 mmHg [101–142] and 116 mmHg [87–154]. Average compliance (41 ml/cmH2O [32–52] vs. 36 ml/cmH2O [27–42], p = 0.045) and ventilatory ratio (2.1 [1.7–2.3] vs. 1.6 [1.4–2.1], p = 0.032) were slightly higher in COVID-19 patients. Inter-individual variability (ratio of standard deviation to mean) of compliance was 36% in COVID-19 patients and 31% in other ARDS. In COVID-19 patients, PaO2/FiO2 was linearly correlated with respiratory system compliance (r = 0.52 p = 0.003). High PEEP improved PaO2/FiO2 in both cohorts, but more remarkably in COVID-19 patients (p = 0.005). Recruitability was not different between cohorts (p = 0.39) and was highly inter-individually variable (72% in COVID-19 patients and 64% in ARDS from other causes). In COVID-19 patients, recruitability was independent from oxygenation and respiratory mechanics changes due to PEEP.

Conclusions

Early after establishment of mechanical ventilation, COVID-19 patients follow ARDS physiology, with compliance reduction related to the degree of hypoxemia, and inter-individually variable respiratory mechanics and recruitability. Physiological differences between ARDS from COVID-19 and other causes appear small.
Appendix
Available only for authorised users
Literature
1.
Guan W, Ni Z, Hu Y, Liang W-H, Ou C, He J, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020;382:1708–20.
2.
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020.
3.
Del Rio C, Malani PN. COVID-19-new insights on a rapidly changing epidemic. JAMA. 2020.
4.
Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A, et al. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region. Italy JAMA. 2020;24:122.
5.
Cao J, Hu X, Cheng W, Yu L, Tu W-J, Liu Q. Clinical features and short-term outcomes of 18 patients with corona virus disease 2019 in intensive care unit. Intensive Care Med. 2020;46:851–3.
6.
Murthy S, Gomersall CD, Fowler RA. Care for critically ill patients with COVID-19. JAMA. 2020.
7.
Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020;2600:1–7.
8.
Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020;10022:1–8.
9.
Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, et al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington State. JAMA. 2020.
10.
11.
Laffey JG, Bellani G, Pham T, Fan E, Madotto F, Bajwa EK, et al. Potentially modifiable factors contributing to outcome from acute respiratory distress syndrome: the LUNG SAFE study. Intensive Care Med. 2016;42:1865–76.PubMedCrossRef
12.
Henderson WR, Chen L, Amato MBP, Brochard LJ. Fifty years of research in ARDS. Respiratory mechanics in acute respiratory distress syndrome. Am J Respir Crit Care Med. 2017;196:822–33.PubMedCrossRef
13.
Amato MBP, Meade MO, Slutsky AS, Brochard L, Costa ELV, Schoenfeld DA, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372:747–55.PubMedCrossRef
14.
Bellani G, Laffey JG, Pham T, Fan E, Brochard L, Esteban A, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315:788–800.PubMedCrossRef
15.
Goligher EC, Dres M, Patel BK, Sahetya SK, Beitler JR, Telias I, et al. Lung and diaphragm-protective ventilation. Am J Respir Crit Care Med. 2020.
16.
Tobin MJ. Basing respiratory management of coronavirus on physiological principles. Am J Respir Crit Care Med. 2020;60141:1–9.
17.
Marini JJ, Gattinoni L. Management of COVID-19 respiratory distress. JAMA. 2020.
18.
Gattinoni L, Chiumello D, Caironi P, Busana M, Romitti F, Brazzi L, et al. COVID-19 pneumonia: different respiratory treatments for different phenotypes? Intensive Care Med. 2020;46:1099–102.PubMedCrossRefPubMedCentral
19.
Haudebourg A-F, Perier F, Tuffet S, de Prost N, Razazi K, Mekontso Dessap A, et al. Respiratory mechanics of COVID-19- versus non-COVID-19-associated acute respiratory distress syndrome. Am J Respir Crit Care Med. 2020;202:287–90.PubMedPubMedCentralCrossRef
20.
Pan C, Chen L, Lu C, Zhang W, Xia J-AA, Sklar MC, et al. Lung Recruitability in SARS-CoV-2 Associated Acute Respiratory Distress Syndrome: A Single-center, Observational Study. Am J Respir Crit Care Med. 2020;201:1294–7.
21.
Liu X, Liu X, Xu Y, Xu Z, Huang Y, Chen S, et al. Ventilatory Ratio in Hypercapnic Mechanically Ventilated Patients with COVID-19-associated Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2020;201:1297–9.
22.
Mauri T, Spinelli E, Scotti E, Colussi G, Basile MC, Crotti S, et al. Potential for lung recruitment and ventilation-perfusion mismatch in patients with the acute respiratory distress syndrome from coronavirus disease. Crit Care Med. 2019;2020:1–6.
23.
Beloncle FM, Pavlovsky B, Desprez C, Fage N, Olivier P-Y, Asfar P, et al. Recruitability and effect of PEEP in SARS-Cov-2-associated acute respiratory distress syndrome. Ann Intensive Care. 2020;10:55.PubMedPubMedCentralCrossRef
24.
Definition Task Force ARDS, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307:2526–33.
25.
Caironi P, Carlesso E, Cressoni M, Chiumello D, Moerer O, Chiurazzi C, et al. Lung recruitability is better estimated according to the Berlin definition of acute respiratory distress syndrome at standard 5 cm H2O rather than higher positive end-expiratory pressure. Crit Care Med. 2015;43:781–90.PubMedCrossRef
26.
Papazian L, Forel J-M, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363:1107–16.PubMedCrossRef
27.
Sinha P, Calfee CS, Beitler JR, Soni N, Ho K, Matthay MA, et al. Physiologic analysis and clinical performance of the ventilatory ratio in acute respiratory distress syndrome. Am J Respir Crit Care Med. 2019;199:333–41.PubMedPubMedCentralCrossRef
28.
Chen L, Chen G-Q, Shore K, Shklar O, Martins C, Devenyi B, et al. Implementing a bedside assessment of respiratory mechanics in patients with acute respiratory distress syndrome. Crit Care. 2017;21:84.PubMedPubMedCentralCrossRef
29.
Chen L, Del Sorbo L, Grieco DL, Junhasavasdikul D, Rittayamai N, Soliman I, et al. Potential for lung recruitment estimated by the recruitment-to-inflation ratio in acute respiratory distress syndrome. A clinical trial. Am J Respir Crit Care Med. 2020;201:178–87.PubMedCrossRef
30.
Yonis H, Mortaza S, Baboi L, Mercat A, Guérin C. Expiratory flow limitation assessment in patients with acute respiratory distress syndrome. A reappraisal. Am J Respir Crit Care Med. 2018;198:131–4.PubMedCrossRef
31.
Grieco DL, Anzellotti GM, Russo A, Bongiovanni F, Costantini B, D’Indinosante M, et al. Airway closure during surgical pneumoperitoneum in obese patients. Anesthesiology. 2019;131:58–73.PubMedCrossRef
32.
Chen L, Del Sorbo L, Grieco DL, Shklar O, Junhasavasdikul D, Telias I, et al. Airway closure in acute respiratory distress syndrome: an underestimated and misinterpreted phenomenon. Am J Respir Crit Care Med. 2018;197:132–6.PubMedCrossRef
33.
Volta CA, Dalla Corte F, Ragazzi R, Marangoni E, Fogagnolo A, Scaramuzzo G, et al. Expiratory flow limitation in intensive care: prevalence and risk factors. Crit Care. 2019;23:395.PubMedPubMedCentralCrossRef
34.
Gattinoni L, Coppola S, Cressoni M, Busana M, Rossi S, Chiumello D. COVID-19 Does Not Lead to a “Typical” Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2020;201:1299–300.
35.
Gattinoni L, Pesenti A, Avalli L, Rossi F, Bombino M. Pressure-volume curve of total respiratory system in acute respiratory failure. Computed tomographic scan study. Am Rev Respir Dis. 1987;136:730–6.PubMedCrossRef
36.
Grieco DL, Russo A, Romanò B, Anzellotti GM, Ciocchetti P, Torrini F, et al. Lung volumes, respiratory mechanics and dynamic strain during general anaesthesia. Br J Anaesth. 2018;121:1156–65.PubMedCrossRef
37.
Gattinoni L, Marini JJ, Pesenti A, Quintel M, Mancebo J, Brochard L. The “baby lung” became an adult. Intensive Care Med. 2016;42:663–73.PubMedCrossRef
38.
39.
Ferrando C, Suarez-Sipmann F, Mellado-Artigas R, Hernández M, Gea A, Arruti E, et al. Clinical features, ventilatory management, and outcome of ARDS caused by COVID-19 are similar to other causes of ARDS. Intensive Care Med. 2020.
40.
Laverdure F, Delaporte A, Bouteau A, Genty T, Decailliot F, Stéphan F. Impact of initial respiratory compliance in ventilated patients with acute respiratory distress syndrome related to COVID-19. Crit Care. 2020;24:412.PubMedPubMedCentralCrossRef
41.
Diehl J-L, Peron N, Chocron R, Debuc B, Guerot E, Hauw-Berlemont C, et al. Respiratory mechanics and gas exchanges in the early course of COVID-19 ARDS: a hypothesis-generating study. Ann Intensive Care. 2020;10:95.PubMedPubMedCentralCrossRef
42.
Fan E, Beitler JR, Brochard L, Calfee CS, Ferguson ND, Slutsky AS, et al. COVID-19-associated acute respiratory distress syndrome: is a different approach to management warranted? Lancet Respir Med. 2020;2600:1–6.
43.
Spinelli E, Grieco DL, Mauri T. A personalized approach to the acute respiratory distress syndrome: recent advances and future challenges. J Thorac Dis. 2019;11:5619–25.PubMedPubMedCentralCrossRef
44.
Fan E, Del Sorbo L, Goligher EC, Hodgson CL, Munshi L, Walkey AJ, et al. An official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2017;195:1253–63.PubMedCrossRef
45.
Santamarina MG, Boisier D, Contreras R, Baque M, Volpacchio M, Beddings I. COVID-19: a hypothesis regarding the ventilation-perfusion mismatch. Crit Care. 2020;24:395.PubMedPubMedCentralCrossRef
46.
Tomashefski JF, Davies P, Boggis C, Greene R, Zapol WM, Reid LM. The pulmonary vascular lesions of the adult respiratory distress syndrome. Am J Pathol. 1983;112:112–26.PubMedPubMedCentral
47.
Leisman DE, Deutschman CS, Legrand M. Facing COVID-19 in the ICU: vascular dysfunction, thrombosis, and dysregulated inflammation. Intensive Care Med. 2020;46:1105–8.
48.
Pintado M-C, de Pablo R, Trascasa M, Milicua J-M, Rogero S, Daguerre M, et al. Individualized PEEP setting in subjects with ARDS: a randomized controlled pilot study. Respir Care. 2013;58:1416–23.PubMedCrossRef
49.
Eronia N, Mauri T, Maffezzini E, Gatti S, Bronco A, Alban L, et al. Bedside selection of positive end-expiratory pressure by electrical impedance tomography in hypoxemic patients: a feasibility study. Ann Intensive Care. 2017;7:76.PubMedPubMedCentralCrossRef
50.
Bellani G, Guerra L, Musch G, Zanella A, Patroniti N, Mauri T, et al. Lung regional metabolic activity and gas volume changes induced by tidal ventilation in patients with acute lung injury. Am J Respir Crit Care Med. 2011;183:1193–9.PubMedPubMedCentralCrossRef
51.
Chiumello D, Carlesso E, Cadringher P, Caironi P, Valenza F, Polli F, et al. Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. Am J Respir Crit Care Med. 2008;178:346–55.PubMedCrossRef
52.
Protti A, Andreis DT, Monti M, Santini A, Sparacino CC, Langer T, et al. Lung stress and strain during mechanical ventilation: any difference between statics and dynamics? Crit Care Med. 2013;41:1046–55.PubMedCrossRef
53.
Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators, Cavalcanti AB, Suzumura ÉA, Laranjeira LN, de Paisani DM, Damiani LP, et al. Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA. 2017;318:1335–45.CrossRef
54.
Grieco DL, Menga LS, Raggi V, Bongiovanni F, Anzellotti GM, Tanzarella ES, et al. Physiological comparison of high-flow nasal cannula and helmet noninvasive ventilation in acute hypoxemic respiratory failure. Am J Respir Crit Care Med. 2020;201:303–12.PubMedCrossRef
55.
Grieco DL, Menga LS, Eleuteri D, Antonelli M. Patient self-inflicted lung injury: implications for acute hypoxemic respiratory failure and ARDS patients on non-invasive support. Minerva Anestesiol. 2019;85:1014–23.PubMedCrossRef
56.
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.PubMedCrossRef
57.
Pan C, Chen L, Lu C, Zhang W, Xia JA, Sklar MC, et al. Lung recruitability in COVID-19-associated acute respiratory distress syndrome: a single-center observational study. Am J Respir Crit Care Med. 2020;201:1294–7.PubMedPubMedCentralCrossRef
Metadata
Title
Respiratory physiology of COVID-19-induced respiratory failure compared to ARDS of other etiologies
Authors
Domenico Luca Grieco
Filippo Bongiovanni
Lu Chen
Luca S. Menga
Salvatore Lucio Cutuli
Gabriele Pintaudi
Simone Carelli
Teresa Michi
Flava Torrini
Gianmarco Lombardi
Gian Marco Anzellotti
Gennaro De Pascale
Andrea Urbani
Maria Grazia Bocci
Eloisa S. Tanzarella
Giuseppe Bello
Antonio M. Dell’Anna
Salvatore M. Maggiore
Laurent Brochard
Massimo Antonelli
Publication date
01-12-2020
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2020
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-020-03253-2

Other articles of this Issue 1/2020

Critical Care 1/2020 Go to the issue

Research

High flow nasal therapy versus noninvasive ventilation as initial ventilatory strategy in COPD exacerbation: a multicenter non-inferiority randomized trial

Research letter

Incidence of ARDS and outcomes in hospitalized patients with COVID-19: a global literature survey

Letter

Hepcidin is described as the master regulator of iron: could its removal by CRRT lead to iron dysmetabolism in the critically ill?

Research Letter

Feasibility study of a portable transparent vinyl chloride shield for use in an ambulance during the COVID-19 pandemic

Research

Omega-3 fatty acid-containing parenteral nutrition in ICU patients: systematic review with meta-analysis and cost-effectiveness analysis

Letter

Potential benefit of angiotensin II in COVID-19 patients: beyond reasonable doubt?