Coronavirus | July 13, 2022 | FREE
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Higher dose of dexamethasone, noninvasive ventilation didn't improve COVID-19 mortality

A randomized trial compared two doses of dexamethasone as well as high-flow nasal oxygen, continuous positive airway pressure, and standard oxygen support in ICU patients with COVID-19 and respiratory failure and found no significant differences.

A higher dose of dexamethasone did not improve outcomes in ICU patients with COVID-19, nor did the choice of oxygenation strategy for patients not on mechanical ventilation, a recent trial showed.

The trial was conducted in 19 ICUs in France from April 2020 to January 2021. Patients with severe acute hypoxemic respiratory failure caused by COVID-19 pneumonia were randomized to standard dexamethasone (dexamethasone-phosphate, 6 mg/d for 10 days [or placebo prior to release of the RECOVERY trial results]) or high-dose dexamethasone (20 mg/d on days 1-5, 10 mg/d on days 6-10). Those not requiring invasive mechanical ventilation were also randomized to high-flow nasal oxygen (HFNO), continuous positive airway pressure (CPAP), or standard of care oxygen support. Results were published by JAMA Internal Medicine on July 5.

There was no difference in 60-day mortality between patients in the standard dexamethasone (n=276, including 37 patients who received placebo) and high-dose dexamethasone (n=270) groups (hazard ratio [HR], 0.96 [95% CI, 0.69 to 1.33]; P=0.79). Similarly, there was no significant difference in patients' 60-day mortality or need for mechanical ventilation according to whether they received standard oxygen (n=109, including 56 receiving standard dexamethasone), CPAP (n=109, including 57 receiving standard dexamethasone), or HFNO (n=115, including 56 receiving standard dexamethasone).

The study authors noted that the benefits of high-dose dexamethasone in patients with COVID-19 are uncertain and that a few recent studies have failed to find an effect on mortality. “To our knowledge, this was the first [randomized controlled trial] that investigated fully randomly assigned oxygenation strategies in patients admitted and carefully surveyed in ICUs,” they said. The results support the use of standard oxygen over CPAP or HFNO for hospitalized patients with COVID-19, the authors concluded, although they noted that effects of noninvasive ventilation strategies provided before ICU admission require further research.