dexamethasone and oxygen support strategies in icu patients with covid-19 pneumonia

Conditions: Acute Hypoxemic Respiratory Failure; COVID-19

Summary: the main manifestation of covid-19 is acute hypoxemic respiratory failure (ahrf). in patients with ahrf, the need for invasive mechanical ventilation is associated with high mortality. two hypotheses will be tested in this study. the first hypothesis is the benefit of corticosteroid therapy on severe covid-19 infection admitted in icu in terms of survival. the second hypothesis is that, in the subset of patients free of mechanical ventilation at admission, either continuous positive airway pressure (cpap) or high-flow nasal oxygen (hfno) allows to reduce intubation rate safely during covid-19 related acute hypoxemic respiratory failure.

the main manifestation of covid-19 is acute hypoxemic respiratory failure (ahrf). in patients with ahrf, the need for invasive mechanical ventilation is associated with high mortality. two hypotheses will be tested in this study. the first hypothesis is the benefit of corticosteroid therapy on severe covid-19 infection admitted in icu in terms of survival. the second hypothesis is that, in the subset of patients free of mechanical ventilation at admission, either continuous positive airway pressure (cpap) or high-flow nasal oxygen (hfno) allows to reduce intubation rate safely during covid-19 related acute hypoxemic respiratory failure. the main objective is to assess the impact of dexamethasone on overall mortality at day-60 after randomization in patients admitted in icu for severe covid-19 infection. in non mechanical ventilation (mv) patients, the additional objective is to assess whether oxygen support based on either hfno or cpap modality in covid-19 related ahrf reduces the need for mechanical ventilation at day-28. an ancillary study cacao (covidicus air contamination) will be performed in 4 centers aiming at assessing the environmental contamination by sars-cov-2 according to the oxygen support modality. additional funding will be searched for these analyses (submitted for anr call). a metanalysis on individual data will be performed using patients enrolled in the 3 phrc flash exploring the activity of corticosteroids.

Eligibility criteria:
inclusion criteria: 1. age ≥ 18 years 2. admitted to icu within 48 hours 3. confirmed or highly suspected covid-19 infection 4. acute hypoxemic respiratory failure (pao2 \ 30/min or labored breathing or respiratory distress; need for oxygen flow \>=6l/min) 5. any treatment intended to treat the sars-cov-2 infection in the absence of contraindications (either as a compassionate use or in the context of a clinical trial, i.e remdesivir, lopinavir/ritonavir, favipiravir, hydroxychloroquine and any other new drug with potential activity). non-inclusion criteria: 1. moribund status 2. pregnancy or breastfeeding 3. long term corticotherapy at a dose of 0.5mg/kg/j or higher 4. active and untreated bacterial, fungal or parasitic infection 5. not written informed consent from the patient or a legal representative if appropriate . if absence a legal representative the patient may be included in emergency procedure 6. hypersensitivity to dexamethasone or to any of the excipients 7. not affiliation to the french social security

Keywords: covid-19 acute hypoxemic respiratory failure (ahrf)