Noninvasive Ventilation in COVID-19 Patients Aged ≥ 70 Years

A Prospective Multicentre Cohort Study

Kamil Polok; Jakub Fronczek; Antonio Artigas; Hans Flaatten; Bertrand Guidet; Dylan W. De Lange; Jesper Fjolner; Susannah Leaver; Michael Beil; Sigal Sviri; Raphael Romano Bruno; Bernhard Wernly; Bernardo Bollen Pinto; Joerg C. Schefold; Dorota Studzińska; Michael Joannidis; Sandra Oeyen; Brian Marsh; Finn H. Andersen; Rui Moreno; Maurizio Cecconi; Christian Jung; Wojciech Szczeklik


Crit Care. 2022;26(224) 

In This Article

Abstract and Introduction


Background: Noninvasive ventilation (NIV) is a promising alternative to invasive mechanical ventilation (IMV) with a particular importance amidst the shortage of intensive care unit (ICU) beds during the COVID-19 pandemic. We aimed to evaluate the use of NIV in Europe and factors associated with outcomes of patients treated with NIV.

Methods: This is a substudy of COVIP study—an international prospective observational study enrolling patients aged ≥ 70 years with confirmed COVID-19 treated in ICU. We enrolled patients in 156 ICUs across 15 European countries between March 2020 and April 2021.The primary endpoint was 30-day mortality.

Results: Cohort included 3074 patients, most of whom were male (2197/3074, 71.4%) at the mean age of 75.7 years (SD 4.6). NIV frequency was 25.7% and varied from 1.1 to 62.0% between participating countries. Primary NIV failure, defined as need for endotracheal intubation or death within 30 days since ICU admission, occurred in 470/629 (74.7%) of patients. Factors associated with increased NIV failure risk were higher Sequential Organ Failure Assessment (SOFA) score (OR 3.73, 95% CI 2.36–5.90) and Clinical Frailty Scale (CFS) on admission (OR 1.46, 95% CI 1.06–2.00). Patients initially treated with NIV (n = 630) lived for 1.36 fewer days (95% CI − 2.27 to − 0.46 days) compared to primary IMV group (n = 1876).

Conclusions: Frequency of NIV use varies across European countries. Higher severity of illness and more severe frailty were associated with a risk of NIV failure among critically ill older adults with COVID-19. Primary IMV was associated with better outcomes than primary NIV.

Clinical Trial Registration: NCT04321265, registered 19 March 2020,


Coronavirus disease 2019 (COVID-19) led to an unprecedented disruption of everyday life and insufficiency of healthcare systems around the world.[1] As a result, tremendous efforts were made by researchers to elucidate the disease pathophysiology, find effective treatments, and develop vaccines.[2–5] COVID-19 typically involves the respiratory system and may lead to an acute respiratory distress syndrome (ARDS) with a poor prognosis and frequent need for invasive mechanical ventilation.[6] It is estimated that approximately 9% of hospitalized patients become critically ill and require transfer to an intensive care unit (ICU).[7] Unfortunately, the sheer volume of the most severely ill patients repeatedly led to an overload of ICUs. As a consequence, the management of severe hypoxemic acute respiratory failure (ARF) required an adjustment to the reality of the global pandemic.

According to the current guidelines, the primary method of respiratory support in patients with ARDS is invasive mechanical ventilation (IMV). Conversely, noninvasive ventilation (NIV) is reserved for selected patients with mild ARDS. It should be used with caution and in constant preparedness for endotracheal intubation.[8] However, due to the shortage of available ICU beds, a significant proportion of COVID-19 patients with ARDS have been treated with noninvasive methods, including high-flow oxygen therapy and noninvasive ventilation, often outside the ICU.[9–11] This approach was based on available evidence of reduced intubation and mortality rates in patients with hypoxemic non-hypercapnic ARF treated with NIV.[12]

Due to multimorbidity and frailty, critically ill elderly patients have a particularly poor prognosis.[13] Similar analyses among patients with COVID-19 confirmed that increasing age and degree of frailty are related to worse outcomes in this population.[14] Compared to NIV, endotracheal intubation and IMV are associated with more discomfort and a higher risk of complications, e.g., ventilator-associated pneumonia. Hence, NIV may be a particularly appealing therapeutic option in elderly patients with COVID-19, including those with the "do not intubate" order. The available evidence suggests that NIV is superior to high-flow nasal oxygen therapy (HFNOT) and conventional oxygen therapy in terms of decreasing 30-day intubation rate in these patients, although no effect on mortality was observed.[15,16] To date, there are no large-scale studies describing the use of NIV among old patients in Europe and evaluating outcomes in this clinical context.

This substudy of the COVIP study aimed to describe the use of NIV in critically ill older adults with COVID-19 admitted to European ICUs. Moreover, we attempted to assess the outcomes in patients treated with NIV, identify risk factors for NIV failure, and compare the effects of primary NIV and primary IMV in this population.