On the other hand, IMV can cause ventilator-induced lung injury ( Herasevich et al., 2011 Cressoni et al., 2016), and patients on IMV usually require large dose of sedatives, analgesics and even neuromuscular blockades ( Jakob et al., 2012 Bellani et al., 2016 Chang et al., 2020). On the one hand, IMV is able to reverse catastrophic hypoxemia and maintain tissue oxygenation, which is life-saving for COVID-19 patients with severe hypoxemia. The timing of initiation of IMV is not standardized and is mainly determined by subjective judgement. In clinical practice, the judgement of вЂњworseningвЂќ is subjective and varied substantially between different institutions and physicians. This recommendation is based on best practice statement and there is no data on when IMV should be initiated. For example, the guideline recommends вЂњclose monitoring for worsening of respiratory status, and early intubation in a controlled setting if worsening occursвЂќ ( Alhazzani et al., 2020). However, there is no specific recommendations for the timing of transition from non-invasive support to IMV, and the recommendations are largely based on expert opinions.

The surviving sepsis guideline of critically ill COVID-19 patients recommended use of oxygen supplementation to maintain pulse oximetry >90%, followed by non-invasive mechanical ventilation (NIV), high-flow nasal canula (HFNC), invasive mechanical ventilation (IMV) and extracorporeal membrane oxygenation (ECMO). Respiratory support becomes important for this type of severe patients ( Yang et al., 2020). A substantial number of patients (19%) infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) will develop respiratory distress and acute lung injury ( Wu & McGoogan, 2020 Ruan et al., 2020). The fatality rate was reported to be around 5% all over the world ( Phua et al., 2020). The study developed a novel predictor COD which considered both magnitude and duration of hypoxemia, to assist risk stratification of COVID-19 patients with acute respiratory distress.Д¬oronavirus disease 2019 (COVID-19) has spread all over the world since its first outbreak in Wuhan, China in December 2019 ( Wang et al., 2020 Novel Coronavirus Pneumonia Emergency Response Epidemiology Team, 2020). day had higher risk of fatality (HR: 3.79, 95% CI p = 0.037), and those with COD > 50 mmHg.

Patients with IMV had substantially lower PaO 2 (62 (49, 89) vs. ResultsДЄ number of 111 patients including 80 in the non-IMV group and 31 in the IMV group were included. The predictive performance of COD was calculated in multivariable Cox regression models. A higher value of COD indicated more oxygen deficit. COD was defined to account for both the magnitude and duration of hypoxemia.

The study was conducted in four designated hospitals for treating COVID-19 patients in Jingmen, Wuhan, from January to March 2020. The study aimed to develop a novel predictor called cumulative oxygen deficit (COD) for the risk stratification. The timing of invasive mechanical ventilation (IMV) is controversial in COVID-19 patients with acute respiratory hypoxemia. Cumulative oxygen deficit is a novel predictor for the timing of invasive mechanical ventilation in COVID-19 patients with respiratory distress. Cite this article Ge H, Zhou J, Lv F, Zhang J, Yi J, Yang C, Zhang L, Zhou Y, Ren B, Pan Q, Zhang Z. For attribution, the original author(s), title, publication source (PeerJ) and either DOI or URL of the article must be cited. Licence This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, reproduction and adaptation in any medium and for any purpose provided that it is properly attributed. 8 Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China DOI 10.7717/peerj.10497 Published Accepted Received Academic Editor Eric Bauman Subject Areas Emergency and Critical Care, Respiratory Medicine Keywords COVID-19, Mechanical ventilation, Intubation, Oxygenation Copyright В© 2020 Ge et al.

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