Discussion Guide for the Botsch Article

The COVID-19 pandemic contributed to an unprecedented increase in patients requiring an intensive care unit (ICU) stay for management of acute respiratory distress syndrome (ARDS) due to viral pneumonia. The pandemic also engendered a marked imbalance between the demand for and the supply of mechanical ventilators, leading to increased reliance on noninvasive ventilation (NIV; eg, continuous positive airway pressure and bilevel positive airway pressure). Typically, NIV is used with caution in patients with ARDS because of the potential risks of delayed intubation and increased mortality and the challenges in achieving adequate ventilation and oxygenation in severely hypoxemic conditions. However, investigators have reported negative associations between NIV use and the need for invasive mechanical ventilation among patients with hypoxemic respiratory failure before and during the pandemic. These findings are not observed consistently, though; other teams have reported associations between NIV use and higher rates of treatment failure and escalation to invasive mechanical ventilation—especially in severe cases of ARDS—highlighting the complexity and variability in responses to NIV across different clinical settings and patient populations. Given this lack of consensus, the authors of the present study examined the associations between NIV use, progression to intubation, and hospital mortality among adults with moderate to severe ARDS due to SARS-CoV-2 pneumonia.The authors conducted a retrospective cohort study of 823 patients with moderate to severe ARDS from SARS-CoV-2 pneumonia who did not have an advance directive precluding endotracheal intubation. These patients were predominantly male (58%) and White (76%). Nearly 45% of patients received NIV and 99% of the remaining patients received high-flow nasal cannula therapy. Patient-related factors associated with NIV use included a history of chronic respiratory disease (eg, asthma) and organ dysfunction. Compared with non-NIV recipients, a larger proportion of those treated with NIV eventually required mechanical ventilation (34% vs 67%) or died during the hospitalization or were discharged to hospice (20% vs 47%). The odds of being intubated were 3.7 times greater for NIV recipients, with obesity, pulmonary function at ARDS onset, cardiovascular disease, and organ dysfunction serving as independent risk factors for intubation. Of patients who eventually required intubation (49%), the odds of mortality were 2.6 times greater for NIV recipients. The authors concluded that the use of NIV in this population is linked with higher rates of subsequent intubation and increased mortality, underlining the need for careful selection of patients and early identification of NIV failure to try to improve outcomes.Alexander A. Botsch, MSN, APRN-CNP, corresponding author for this article, cites his experiences as a nurse practitioner during the pandemic as motivation to conduct this work. Having spent "countless hours in the ICU" during the pandemic's early stages, he had grown accustomed to the treatment plan for those who developed severe respiratory failure: "intubation, paralysis, pronation." However, in light of the global research efforts aimed at managing severe COVID-19 infections, "it seemed new data were emerging every week, often contradicting the previous dogma to which we had adhered." For example, he noticed that providers were increasingly reliant on NIV. Yet, from his perspective, "NIV seemed to provide temporary relief at most, but I felt most patients ended up progressing to intubation before long and NIV simply delayed the inevitable." He noticed that "patients seemed to do better when they were intubated sooner," but the lack of consistent evidence further perpetuated inconsistencies in patient management during the early progression of ARDS. Inspired by this lack of consistency, he sought to see if NIV was associated with poorer clinical outcomes.Although he had been involved in prior academic endeavors, this was the first study where Mr Botsch was the lead investigator. Before recruiting other team members, he had to reconcile his experiences as a clinician with the data available in the literature. Because the COVID-19 pandemic was such a rapidly evolving phenomenon, he needed to "search the literature throughout the drafting of the manuscript to make sure we were reporting accurate data." He adds, "the initial literature review and references cited on the final manuscript looked vastly different from one another." Once familiar with the literature, he identified a diverse group of health care professionals who each "brought separate skills to the table" and proposed using an institutionally developed COVID-19 database to answer the project's research questions.Remaining flexible as a researcher was essential: "the project started as something totally different; we planned to compare modalities of oxygen delivery." However, after diving into the data, the research team found that "there were so many confounding variables that we could not really make reasonable conclusions of how to apply it clinically." The team eventually decided to alter the project's research questions so that they could "draw better conclusions from that data." From Mr Botsch's perspective, this process exemplified his team's chemistry: "because the group was composed of individuals with diverse skill sets, we were able to have open communication about the research question and methods and ultimately were able to clarify the vision further."Mr Botsch believes this project adds to the "vast array of data with conflicting outcomes in the literature regarding this topic" and encourages clinicians to "think twice about utilizing NIV in patients with SARS-CoV-2 ARDS." However, with most of the available data coming from retrospective studies, clinicians should remain cautious in their interpretation of these findings, given the inherent limitations such as potential biases and lack of controlled variables.This feature briefly describes the personal journey and background story of the EBR article's lead investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.Alexander A. Botsch, MSN, APRN-CNP, worked as a bedside nurse in the emergency department and medical ICU for several years, yet "was unable to find fulfillment without a deeper understanding of the care I was providing." Therefore, he completed an acute care nurse practitioner program in 2015 and has been predominantly practicing in pulmonary critical care ever since, feeling "drawn to the challenge of supporting the most acutely ill patients in the hospital." He encourages clinicians to reflect on what kind of impact they wish to make on health care. He hopes to make his impact by involving himself in "academic works that either develop, change, or reaffirm practices to improve the quality of critical care delivery."