Infectious diseases

COVID-19: hospital ‘successfully’ covering ICU with ward-based CPAP

Patients with COVID-19 respiratory failure can be managed with CPAP on a standard medical ward without any increase in mortality compared to placing them in ICU, an Australian hospital team have reported.

The message is based on an observational study during last year’s Delta outbreak at western Sydney’s Nepean Hospital, which established two higher-acuity COVID-19 wards overseen by respiratory and ID physicians. These were in addition to two regular COVID-19 wards and a full intensive care unit.

As a result, almost 22% of the 137 COVID-19 patients admitted to the hospital between July and September last year were able to be given CPAP on their ward, with another 16% receiving CPAP within ICU.

Despite the different resources available between these two settings, there were only four deaths in the ward CPAP group compared to three deaths on the same treatment in ICU, the team reported.

With no significant difference in mortality between the two groups, they said this demonstrated the attempt had been “successful”.

“The similar mortality rates between ward CPAP and ICU CPAP provide a reassuring signal that this therapy can be delivered safely during a pandemic in a medical ward environment,” they wrote in Internal Medicine Journal (link).

“As CPAP can reduce progression to invasive ventilation, our data suggests we can take steps on a medical ward to reduce the need for more invasive and resource-hungry therapies.”

There were still heavy staffing demands even outside of ICU, with on-call respiratory physicians rostered around the clock and consulted for each case potentially regarding ward CPAP.

And nursing support was also “vital”, the team said, adding that one nurse was allocated for every two patients on ward CPAP initially, a ratio that declined to 1:4 as patient numbers grew and staff availability declined.

“Where possible CPAP patients were grouped in multi-bed bays to help maintain appropriate supervision,” they wrote.

The team said patients were only referred to ICU with haemodynamic instability (e.g. persistent hypotension despite appropriate fluid resuscitation) or when they were unable to maintain adequate oxygenation with ward-based treatment.

Under these criteria, 37% of those admitted to the hospital’s COVID-19 wards were transferred to ICU at some point, while19 (37% of those in ICU) required intubation for progressive respiratory failure, of which 17 (89%) had been on CPAP prior to intubation. All seven patients transitioned to ECMO died, they said.

Maximal therapy for the rest – some 56 patients in total – consisted of high flow nasal cannulae as their respiratory issues were less serious, the team reported.

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