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Italian pulmonologist units and COVID-19 outbreak: “mind the gap”!

Critical Care volume 24, Article number: 381 (2020) Cite this article

The outbreak of COVID-19 in Italy has shown the inadequacy of the health system to counterbalance a massive request for ICU care [1]. One fourth of > 1500 COVID-19 patients died after the admission in Lombardia ICUs; in only 11% of them, noninvasive ventilation (NIV) and/or high flow nasal cannula (HFNC) was attempted early to prevent respiratory deterioration and invasive mechanical ventilation (IMV). Conversely, in Chinese reports, NIV and HFNC were used respectively in between one third and two thirds of less severely hypoxemic COVID-19 patients keeping lower hospital mortality [2]. The success of noninvasive respiratory assistance in avoiding intubation is higher if attempted earlier in hypoxemic patients (PaO2/FiO2 > 150) [2]. Even after failure, NIV and/or HFNC may be good players to facilitate weaning from IMV and discharge from ICU. Clinical experts-guided hierarchical COVID-19 management strategy including intensivists and pulmonologists might have improved outcomes in some Chinese provinces [3].

The delayed admission in Lombardia overcrowded ICU of severely hypoxemic COVID-19 patients meeting the criteria for IMV without being offered a HFNC/NIV trial must have played a crucial role. Where should have been earlier and properly noninvasively supported acute patients with and without COVID-19 to keep the highest the ICU capacity?

Respiratory high-dependency care units (RHDCUs) are specialised cost-effective environments offering an “intermediate” level of care between ICU and ward, where NIV/HFNC, weaning from IMV and discharge of ventilator-dependent patients are provided [4]. Italian RHDCUs are mainly located inside the pulmonology ward and work following a step-up/step-down flexibility according to changes in clinical status. The “gap” between the Italian RHDCU network and pre-COVID-19 respiratory needs might largely explain ICU network failure in Lombardia [4]. A national survey performed at the beginning and 1 month after the COVID-19 outbreak demonstrated an increase rate (94% vs 12%) of Italian Pulmonologist Units (IPUs) accounting for 841 extra-beds involved in the fight against COVID-19. This was associated with the “up-grading” of 84% IPUs towards RHDCUs. Moreover, 72% of these extra-beds were dedicated to provide NIV/HFNC which avoided intubation/death in 40% of cases (http://www.aiponet.it/news/speciale-covid-19/2463-il-94-delle-pneumologie-e-in-prima-linea-nella-lotta-contro-l-infezione-da-covid-19.html) (Table 1). The expanded IPU network together with national more restrictive measures against virus dissemination after the Lombardia outbreak has contributed to the mitigation of COVID-19 impact on mortality in other regions.

Table 1 Distribution of RHDCU beds at the pre-COVID-19 time and of pulmonologist extra beds during the COVID-19 outbreak according to the different Italian regions
Full size table

In conclusion, what could we learn from the Italian COVID-19 outbreak? The Italian health system needs a stronger pulmonologists/RHDCUs “backbone” for the governance of “ordinary” burden of respiratory diseases to mind the gap against next unforeseen pandemia.

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References

  1. Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A, et al. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region, Italy. JAMA. 2020. https://doi.org/10.1001/jama.2020.5394.

  2. Phua J, Weng L, Ling L, Egi M, Lim CM, Divatia JV, et al. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. Lancet Respir Med. 2020;8:506–17.

  3. Sun Q, Qiu H, Huang M, Yang Y. Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu province. Ann Intensive Care. 2020;10:33. https://doi.org/10.1186/s13613-020-00650-2.

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Acknowledgements

We would like to thank Claudia Diana of AIPO Ricerche for her precious help in analysing the data and performing Table 1.

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Authors and Affiliations

  1. Pulmonology and Respiratory Intensive Care Unit, S Donato Hospital, Via Nenni, 20, 52100, Arezzo, Italy

    Raffaele Scala

  2. Respiratory and Critical Care Unit Cardio-thoracic and Vascular Department Careggi Teaching Hospital, Florence, Italy

    Teresa Renda

  3. Pneumologic Center “Misericordia”, Sesto Fiorentino, Florence, Italy

    Antonio Corrado

  4. Italian Thoracic Society/Italian Association of Hospital Pulmonologists (ITS/AIPO), Florence, Italy

    Adriano Vaghi

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  1. Raffaele Scala
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  2. Teresa Renda
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RS ideated and structured the paper. AC, TR and AV contributed to the writing of the paper. RS revised the final version of the paper.

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Correspondence to Raffaele Scala.

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Scala, R., Renda, T., Corrado, A. et al. Italian pulmonologist units and COVID-19 outbreak: “mind the gap”!. Crit Care 24, 381 (2020). https://doi.org/10.1186/s13054-020-03087-y

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Critical Care

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