Continuous Positive Airway Pressure (CPAP) in Covid 19 Acute Respiratory Distress Syndrome (ARDS): A Systematic Review

Introduction Acute Respiratory Distress Syndrome (ARDS) is a feared consequence of Covid 19 Pneumonia. Traditional guidance was for ARDS to be treated with Intubation and Mechanical Ventilation (IMV), when failing simple oxygen. However globally numbers of patients with Covid 19 ARDS (CARDS) quickly overwhelmed IMV capacity, with Continuous Positive Airway Pressure (CPAP) has been used as a bridge or alternative to IMV. However, the evidence base remains limited in quality despite widespread adoption in guidelines. Methods Pubmed (15.6.2022), Embase (30.7.2022) and Google Scholar (4.8.2022) were searched to identify studies with the primary outcome of IMV free survival in patients with CARDS receiving CPAP, ideally with simple oxygen as a comparator. Secondary outcomes were overall survival with CPAP, length of stay and adverse events. All studies were assessed by the relevant Critical Appraisal Skills Programme Tool (CASP). Results 13 studies were identified, out of which only 1 was a Randomised Control Trial (RCT) with simple oxygen as a comparator. There were 11 Cohort studies and one Systematic review. Discussion There is much heterogeneity in CPAP success rates (50 – 70%), which may be linked to variation in candidate selection, resource setting, application protocols and combined use with other respiratory support modalities (Non Invasive Ventilation – NIV, and High Flow Nasal Oxygen – HFNO). Adverse events and economic data such as length of stay are under reported. Conclusion CPAP is an effective respiratory support in CARDS particularly in resource poor settings. However further research is needed to refine optimum candidate selection, application protocols and any added benefit from combination with NIV or HFNO. No funding was received for this study. This review was not registered.