COVID-19 Acute Respiratory Distress Syndrome: Treatment with Helmet CPAP in Respiratory Intermediate Care Unit by Pulmonologists in the Three Italian Pandemic Waves

HIGHLIGHTS: What are the main findings? Good clinical outcomes with H-CPAP in RICU, especially in mild and moderate CARDS. Significant improvement of prognosis in the three different waves: patients’ diseases were found to be progressively slightly less severe. (No patient had yet received at least one dose of vaccination against COVID-19.). What is the implication of the main finding? H-CPAP success strongly correlates with worst PaO(2)/FiO(2) ratio and D-dimer level at admission. Relevance of proper management during hospitalization by pulmonologists in RICU. ABSTRACT: COVID-19 Acute Respiratory Distress Syndrome (CARDS) is the most serious complication of COVID-19. The SARS-CoV-2 outbreaks rapidly saturated intensive care unit (ICU), forcing the application of non-invasive respiratory support (NIRS) in respiratory intermediate care unit (RICU). The primary aim of this study is to compare the patients’ clinical characteristics and outcomes (Helmet-Continuous Positive Airway Pressure (H-CPAP) success/failure and survival/death). The secondary aim is to evaluate and detect the main predictors of H-CPAP success and survival/death. A total of 515 patients were enrolled in our observational prospective study based on CARDS developed in RICU during the three Italian pandemic waves. All selected patients were treated with H-CPAP. The worst ratio of arterial partial pressure of oxygen (PaO(2)) and fraction of inspired oxygen (FiO(2)) PaO(2)/FiO(2) during H-CPAP stratified the subjects into mild, moderate and severe CARDS. H-CPAP success has increased during the three waves (62%, 69% and 77%, respectively) and the mortality rate has decreased (28%, 21% and 13%). H-CPAP success/failure and survival/death were related to the PaO(2)/FiO(2) (worst score) ratio in H-CPAP and to steroids’ administration. D-dimer at admission, FiO(2) and positive end expiratory pressure (PEEP) were also associated with H-CPAP success. Our study suggests good outcomes with H-CPAP in CARDS in RICU. A widespread use of steroids could play a role.