Sixty-day mortality among 520 Italian hospitalized COVID-19 patients according to the adopted ventilatory strategy in the context of an integrated multidisciplinary clinical organization: a population-based cohort study

Background: Among COVID-19 patients, the decision of which ventilation strategy to adopt is crucial and not guided by existing outcome evidence. We described the clinical characteristics and outcomes of hospitalized COVID-19 patients according to the adopted respiratory strategy. Methods: Population-based cohort study including all COVID-19 patients (26/02/2020-18/04/2020) within Rimini Italian province. Hospitalized patients were classified according to the maximum level of respiratory support: oxygen supplementation (group Oxygen), NIV (group NIV-only), IMV (group IMV-only), and IMV after a NIV trial (group IMV-after-NIV). Sixty-day mortality risk was estimated with a Cox proportional hazard analysis adjusted by age, sex, and administration of steroids, canakinumab, and tocilizumab. Findings: We identified 1,424 symptomatic patients: 520 (36.5%) were hospitalized, the remaining 904 (63.5%) were treated at home with no 60-days death. According to the respiratory support, 408 (78.5%) were assigned to Oxygen, 46 (8.8%) to NIV-only, 25 (4.8%) to IMV-after-NIV, and 41 (7.9%) to IMV-only groups. There was no significant difference in the P/F at IMV inception among IMV-after-NIV and IMV-only groups (p=0.9). Overall 60-day mortality was 24.2% (Oxygen: 23.0%; NIV-only: 19.6%; IMV-after-NIV: 32.0%; IMV-only: 36.6%; p = 0.165). Compared with Oxygen group, the 60-day mortality risk significantly increased for IMV-after-NIV (HR 2.776; p=0.024) and IMV-only group (HR 2.966; p=0.001). Conclusions: This study provides a population-based figure of the impact of the COVID-19 epidemic. A similar 60-days mortality risk was found for patients undergoing immediate IMV and those intubated after a NIV trial. Many patients had a favorable outcome after prolonged IMV.