Epidemiology, Ventilation Management, and Outcomes in Invasively Ventilated Coronavirus Disease 2019 Patients: An Analysis of Four Observational Studies in Four Countries on Two Continents.

Summary

Pooling individual patient data from four national cohorts (n=6,702), ICU mortality for COVID-19 ARDS was markedly higher in Argentina/Brazil than in the Netherlands/Spain despite small differences in ventilation strategies. Propensity score weighting and matching confirmed robust differences, suggesting system-level or resource-related contributors beyond case-mix and ventilator settings.

Key Findings

• ICU mortality was significantly higher in Argentina (59.6%) and Brazil (56.6%) versus the Netherlands (32.1%) and Spain (34.7%) after adjustment (P<0.001).
• Ventilation management differences between countries were small, suggesting limited explanatory power for outcome gaps.
• Ventilator-free days at day 60 were higher in the Netherlands and Spain; propensity score matching confirmed outcome differences.

Clinical Implications

Benchmarking outcomes across systems can inform resource allocation, surge planning, and quality improvement; clinicians should consider system-level constraints when interpreting ARDS mortality and prioritize comprehensive bundles beyond ventilator settings.

Limitations

• Observational design with potential residual confounding and unmeasured system-level variables
• Heterogeneity in data sources and care pathways across countries

Future Directions

Decompose system-level contributors (staffing ratios, ICU strain, adjunct access) via linked administrative/clinical datasets; evaluate effects of standardized ARDS bundles and resource augmentation in LMIC settings.