Reply to Yaroshetskiy et al.: Acute Respiratory Distress Syndrome in COVID-19: Do All These Patients Definitely Require Intubation and Mechanical Ventilation?

From the Authors:

We conducted a retrospective observational cohort study focused solely on intubated patients with coronavirus disease (COVID-19) respiratory failure at two tertiary medical centers (1). It was not a clinical trial and did not include a nonintubated comparator cohort. Dr. Yaroshetskiy and colleagues raise important questions about the use of noninvasive respiratory support for COVID-19, but these are questions that our study was not designed to answer. We can only say that measures of gas exchange, respiratory system compliance, and positive end-expiratory pressure application in our patients were similar to those from prior large cohorts of acute respiratory distress syndrome (ARDS), as detailed in our manuscript. Patients were intubated according to standard clinical criteria and received established evidence-based care for ARDS at the discretion of the treating physician. This included prone positioning for patients with persistent hypoxemia or elevated airway pressures. Measures of gas exchange in patients receiving prone ventilation in our cohort were similar to those in published trials of prone ventilation for ARDS. Neuromuscular blockade was provided at the discretion of the treating physician, and shock was defined as the presence of any inotropes or vasopressors, regardless of level.