OasisLMS

INTRODUCTION: Adherence to guideline-recommended ventilator management for acute respiratory distress syndrome (ARDS) due to COVID-19 is unknown. We sought to evaluate variation in use of ‘guideline-based care’ and adjunctive strategies for COVID-19 ARDS across 55 hospitals contributing to the Society of Critical Care Medicine Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 registry. We hypothesized that COVID-19 ARDS management would vary across hospitals and that hospital-level mortality would be higher at hospitals with lower use of guideline-recommended care as compared to those with higher use. METHODS: In this retrospective, observational study we used multivariable adjusted hierarchical random effects logistic regression to assess hospital-level, risk-adjusted use of ‘guideline-based care’ for ARDS, defined as low tidal volume (low Vt), plateau pressure (Pplat) < 30 cmH2O, and prone position for PaO2:FiO2 ratio (P:F) < 100. RESULTS: Among 2,021 patients with COVID-19 ARDS, 50% received care consistent with ARDS guidelines. After adjusting for demographic, geographic, time, and severity of illness characteristics, hospital of admission contributed to 20% of the risk-adjusted variation in 'guideline-based care’; a patient treated at a hospital with high utilization of recommended therapies had 2.3 times (95% CI 1.3-4.3) the odds of receiving ‘guideline-based care’ as compared to a patient receiving treatment at a randomly selected hospital with lower utilization of ‘guideline-base care.’ Additionally, there was significant hospital level variation in use of paralytics (MOR 4.0, 95% CI 1.6-10.1) and inhaled pulmonary vasodilators (MOR 3.9, 95% CI 1.5-10.2). Mortality was non-significantly lower at hospitals within the highest-use quartile of ‘guideline-based care’ as compared to the lowest-use quartile (risk-adjusted OR 0.5, 95% CI 0.2-1.1, p=0.06). CONCLUSIONS: Only half of patients studied in the international VIRUS registry received guideline-based ventilation strategies for COVID-19 ARDS, with wide variation across hospitals. Given the significant mortality risk associated with COVID-19 ARDS, there is room for improvement in implementation of guideline-recommended ventilator strategies.