• Jamuna K Krishnan, Mangala Rajan, Benjamin R Baer, Katherine L Hoffman, Mark N Alshak, Kerri I Aronson, Parag Goyal, Chiomah Ezeomah, Shanna S Hill, Fernando J Martinez, Meredith L Turetz, Martin T Wells, Monika M Safford, and Edward J Schenck.
• Divison of Pulmonary and Critical Care Medicine, Weill Cornell Department of Medicine, NY, NY, United States of America. Electronic address: jkk9002@med.cornell.edu.
• J Crit Care. 2022 Aug 1; 70: 154045154045.

PurposeProlonged observation could avoid invasive mechanical ventilation (IMV) and related risks in patients with Covid-19 acute respiratory failure (ARF) compared to initiating early IMV. We aimed to determine the association between ARF management strategy and in-hospital mortality.Materials And MethodsPatients in the Weill Cornell Covid-19 registry who developed ARF between March 5 - March 25, 2020 were exposed to an early IMV strategy; between March 26 - April 1, 2020 to an intermediate strategy; and after April 2 to prolonged observation. Cox proportional hazards regression was used to model in-hospital mortality and test an interaction between ARF management strategy and modified sequential organ failure assessment (mSOFA).ResultsAmong 632 patients with ARF, 24% of patients in the early IMV strategy died versus 28% in prolonged observation. At lower mSOFA, prolonged observation was associated with lower mortality compared to early IMV (at mSOFA = 0, HR 0.16 [95% CI 0.04-0.57]). Mortality risk increased in the prolonged observation strategy group with each point increase in mSOFA score (HR 1.29 [95% CI 1.10-1.51], p = 0.002).ConclusionIn Covid-19 ARF, prolonged observation was associated with a mortality benefit at lower mSOFA scores, and increased mortality at higher mSOFA scores compared to early IMV.Copyright © 2022 Elsevier Inc. All rights reserved.

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