The FLARE Four
- Published data on 1,591 ICU patients with COVID-19 in the Lombardy region of Italy is by far the largest ICU cohort reported to date
- 88% of patients received mechanical ventilation within 24 hours of ICU admission
- ICU mortality was higher for patients over 63 years of age and those who had hypertension
- ICU mortality was 26% after limited follow-up time, with 58% of patients still in the ICU at the time of report
- Countering the notion that respiratory failure in COVID-19 is a unique entity, the patients were broadly similar to ARDS patients in the LUNG-SAFE trial
On April 6, 2020, research published in JAMA reported on the largest ICU cohort of patients with COVID-19 to date. Camille Petri, MD, a fellow in Pulmonary and Critical Care Medicine at Massachusetts General Hospital, summarized and critiqued the publication in a fast literature update posted on April 8.
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The retrospective study involved 1,591 patients with confirmed COVID-19 admitted between February 20 and March 18, 2020, to any of 72 ICUs in the Lombardy region of Italy. The median age was 63 (range, 14–91) and 82% of patients were male. The ICU population consisted mostly of mild-to-moderate acute respiratory distress syndrome (ARDS) by Berlin criteria. 68% had one or more comorbidities, most commonly hypertension (49%), CVD (21%) or hypercholesterolemia (18%). Only 4% had COPD.
88% of patients received mechanical ventilation within 24 hours of ICU admission. During the first 24 hours:
- Median PEEP was 14 cmH2O and the maximum was 22 cmH2O
- 89% of patients required FiO2 ≥50%
- Median PaO2/FiO2 was 160
As of March 25, 2020:
- ICU mortality rate — 26% (15% in patients <64 years vs. 36% in older adults, P < .001)
- Median ICU stay — 9 days
There's been speculation that respiratory failure in COVID-19 patients has unique attributes. Yet the patients described here are broadly similar in age, comorbidities and respiratory parameters to those in the LUNG-SAFE trial, the largest observational study of ARDS in the pre–COVID-19 era.
This new study confirms that critically ill COVID-19 patients often require invasive mechanical ventilation with high levels of PEEP and FiO2. Mortality is unknown for now because 58% of patients remained in the ICU at the time of the report. However, overall mortality in LUNG-SAFE was 35%, and 28-day mortality in a Chinese COVID-19 ICU cohort was 28%. On that basis, it's reasonable to expect most critically ill patients with COVID-19 to survive.
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