Reduced ICU demand with early CPAP and proning in COVID-19 at Bradford: a single centre cohort
Background Guidance in the management of COVID-19 respiratory failure has favoured early intubation, with concerns over the use of CPAP. We adopted early CPAP and self-proning, and evaluated the safety and efficacy of this approach. Methods This retrospective observational study included all patients with a positive COVID-19 PCR, and negative patients with high clinical suspicion. Our protocol advised early CPAP and self-proning for severe cases, aiming to prevent rather than respond to deterioration. CPAP was provided outside ICU by ward staff supported by physiotherapists and an intensive critical care outreach program. Data were analysed descriptively and compared against a large UK cohort (ISARIC). Results 559 patients admitted before 1/May/20 were included. 365 were discharged alive, 182 died, and 12 remain inpatient. 165 patients (29.5%) received CPAP, 40 (7.2%) were admitted to ICU and 27 (4.8%) were ventilated. Hospital mortality was 33.3%, ICU mortality 54.5%. Following CPAP 64% of patients with moderate or severe ARDS, who were candidates for escalation, avoided intubation. Figures for ICU admission, intubation and hospital mortality are lower than those from ISARIC, whilst ICU mortality is similar. Following ISARIC proportions we would have admitted 92 patients to ICU and intubated 55. Using the described protocol, we intubated 27 patients from 40 admissions, and remained within our expanded ICU capacity. Conclusion Bradford's protocol produced good results despite our population having high levels of co-morbidity and ethnicities associated with poor outcomes. In particular we avoided overloading ICU capacity. We advocate this approach as both effective and safe.