Six traits predict need for mechanical ventilation in patients with COVID-19
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Among patients hospitalized for COVID-19 in the United States, male sex, age 60 years and older, obesity, chronic kidney disease, cardiovascular disease and living in the Northeast were associated with an increased risk for mechanical ventilation, data show.
The findings, published in Clinical Infectious Diseases, also indicated that the same characteristics, except for obesity, were linked to an increased risk for mortality.
“This was the first attempt to try and get a broader sense of the risk factors for adverse outcome and how they interacted with one another in a much more specific manner,” Robert S. Brown, Jr., MD, MPH, clinical chief of the division of gastroenterology and hepatology at Weill Cornell Medicine Center, told Healio Primary Care.
Researchers reviewed data from 11,721 patients with COVID-19 who were admitted to 245 hospitals across 38 states between Feb. 15 and April 20. Among all patients, 48 received remdesivir (Gilead) and 4,232 received hydroxychloroquine. In addition:
- 59.9% were aged 60 and older;
- 53.4% were men;
- 46.7% had hypertension;
- 27.8% had diabetes;
- 18.6% had CVD;
- 16.1% had obesity;
- 12.2% had chronic kidney disease; and
- 16.8% of patients needed mechanical ventilation.
Patients who required mechanical ventilation were more likely to be:
- men (63.9% vs. 51.3%);
- over the age of 60 years (67.3% vs. 58.4%);
- have a history of chronic kidney disease (15.2% vs. 11.6%), CVD (22.6% vs. 17.8%) or obesity (18.3% vs. 15.7%); and
- live in the Northeast (52.3%) instead of the Midwest (4.1%), West (12%) or South (31.6%).
“We expected to see older age, obesity and cardiovascular disease as risks,” Brown said. “But I was surprised that chronic lung disease and smoking did not seem to be conferring an increased risk. This requires further investigation.”
Researchers also reported a 21.4% mortality rate among hospitalized patients; this rate increased to 70.5% among those on mechanical ventilation. The odds of death were higher among men (adjusted OR = 1.5; 95% CI, 1.3-1.6) and patients aged 60 years and older (adjusted OR = 7.2; 95% CI, 5.4-9.7). Living in the Northeast and having chronic kidney disease or CVD were also associated with mortality (P < .001).
Brown said the findings can help steer efforts to bring the pandemic under control.
“The most common question I get asked as a clinician is, ‘Do my medical conditions merit working from home?’,” he said. “With this data, I have a better sense of how to quantify patient risk vs. factors such as age and comorbid conditions.”
He said the data can also guide early intervention efforts and vaccination priorities.
Perspective
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Iahn Gonsenhauser, MD, MBA
First and foremost, it's important to remember that this study is relatively small, only about 11,000 patients. Consequently, it represents a very limited data set and the findings are purely descriptive, not causal. However, their findings are an affirmation of what we suspected and what we've been saying all along: that older patients and patients with critical comorbidities such as chronic kidney disease, CVD, diabetes and even obesity are associated with worse COVID-19 outcomes and more instances of acute respiratory disease.
In regard to mortality-related findings, we again see the CVD, being older and chronic kidney disease, but one difference is that living in the Northeastern United States was a critical risk factor in increasing mortality. This is probably an artifact of how COVID-19 landed in the U.S., since the Northeast was particularly badly hit in the early days of COVID-19.
It’s also important to point out while the elderly were certainly more likely to die from COVID, there was still a significant portion of young patients who died from COVID-19, as well. So, while we've tended to have this focus on the elderly and those with specific comorbidities, the young and those without comorbidities also had a significant mortality, and we can't overlook considering these patients carefully and cautiously.
The researchers also associated smoking and hypertension with a lower risk for needing mechanical ventilation, which is surprising since high blood pressure often correlates with CVD, but they split those apart and found opposite impact. Certainly, smoking is one that we would generally assume had a negative predictor, or a predictor of bad outcomes, and it didn't in this case. But that may be a result of the size of the study as much as anything else. Researchers also found patients with hypertension and pulmonary disease and who smoked were less likely to die from COVID-19. Given the background of those medical conditions and the inflammatory nature of COVID-19, you would think the opposite would be true. Maybe we don't have enough data to answer that. That could also be, again, a result of the size of study.
Researchers also identified a benefit to early mechanical ventilation vs. later mechanical ventilation, suggesting that perhaps there should be a lower threshold for initiating mechanical ventilation. However, this last point is very case specific and should be based on a physician’s observations, not the findings of a descriptive study.
There were some findings related to hydroxychloroquine and remdesivir but based on the methodology of this study, these are not particularly meaningful findings and should not be used to affect the approach we take to either of these medications.
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