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The Use of High-Flow Nasal Oxygen in the ICU as a First-Line Therapy for Acute Hypoxemic Respiratory Failure Secondary to Coronavirus Disease 2019.

ABSTRACT: Objectives:Limited evidence is available regarding the role of high-flow nasal oxygen in the management of acute hypoxemic respiratory failure secondary to coronavirus disease 2019. Our objective was to characterize outcomes associated with high-flow nasal oxygen use in critically ill adult patients with coronavirus disease 2019-associated acute hypoxemic respiratory failure. Design:Observational cohort study between March 18, 2020, and June 3, 2020. Setting:Nine ICUs at three university-affiliated hospitals in Philadelphia, PA. Patients:Adult ICU patients with confirmed coronavirus disease 2019 infection admitted with acute hypoxemic respiratory failure. Interventions:None. Measurements and Main Results:Of 266 coronavirus disease 2019 ICU admissions during the study period, 124 (46.6%) received some form of noninvasive respiratory support. After exclusions, we analyzed 83 patients who were treated with high-flow nasal oxygen as a first-line therapy at or near the time of ICU admission. Patients were predominantly male (63.9%). The most common comorbidity was hypertension (60.2%). Progression to invasive mechanical ventilation was common, occurring in 58 patients (69.9%). Of these, 30 (51.7%) were intubated on the same day as ICU admission. As of June 30, 2020, hospital mortality rate was 32.9% and the median hospital length of stay was 15 days. Among survivors, the most frequent discharge disposition was home (51.0%). In comparing patients who received high-flow nasal oxygen alone (n = 54) with those who received high-flow nasal oxygen in conjunction with noninvasive positive-pressure ventilation via face mask (n = 29), there were no differences in the rates of endotracheal intubation or other clinical and utilization outcomes. Conclusions:We observed an overall high usage of high-flow nasal oxygen in our cohort of critically ill patients with acute hypoxemic respiratory failure secondary to coronavirus disease 2019. Rates of endotracheal intubation and mortality in this cohort were on par with and certainly not higher than other published series. These findings should prompt further considerations regarding the use of high-flow nasal oxygen in the management algorithm for coronavirus disease 2019-associated acute hypoxemic respiratory failure.

SUBMITTER: McDonough G

PROVIDER: S-EPMC7571957 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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The Use of High-Flow Nasal Oxygen in the ICU as a First-Line Therapy for Acute Hypoxemic Respiratory Failure Secondary to Coronavirus Disease 2019.

McDonough Gregory G Khaing Phue P Treacy Taylor T McGrath Christopher C Yoo Erika J EJ

Critical care explorations 20201016 10

<h4>Objectives</h4>Limited evidence is available regarding the role of high-flow nasal oxygen in the management of acute hypoxemic respiratory failure secondary to coronavirus disease 2019. Our objective was to characterize outcomes associated with high-flow nasal oxygen use in critically ill adult patients with coronavirus disease 2019-associated acute hypoxemic respiratory failure.<h4>Design</h4>Observational cohort study between March 18, 2020, and June 3, 2020.<h4>Setting</h4>Nine ICUs at th ...[more]

PMID: 33134947

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Project description:ObjectivesAn ongoing outbreak of coronavirus disease 2019 is spreading globally. Acute hypoxemic respiratory failure is the most common complication of coronavirus disease 2019. However, the clinical effectiveness of early high-flow nasal oxygen treatment in patients with coronavirus disease 2019 with acute hypoxemic respiratory failure has not been explored. This study aimed to analyze the effectiveness of high-flow nasal oxygen treatment and to identify the variables predicting high-flow nasal oxygen treatment failure in coronavirus disease 2019 patients with acute hypoxemic respiratory failure.DesignA multicenter, retrospective cohort study.SettingThree tertiary hospitals in Wuhan, China.PatientsForty-three confirmed coronavirus disease 2019 adult patients with acute hypoxemic respiratory failure treated with high-flow nasal oxygen.InterventionsNone.Measurements and main resultsMean age of the enrolled patients was 63.0 ± 9.7 years; female patients accounted for 41.9%. High-flow nasal oxygen failure (defined as upgrading respiratory support to positive pressure ventilation or death) was observed in 20 patients (46.5%), of which 13 (30.2%) required endotracheal intubation. Patients with high-flow nasal oxygen success had a higher median oxygen saturation (96.0% vs 93.0%; p < 0.001) at admission than those with high-flow nasal oxygen failure. High-flow nasal oxygen failure was more likely in patients who were older (p = 0.030) and male (p = 0.037), had a significant increase in respiratory rate and a significant decrease in the ratio of oxygen saturation/FIO2 to respiratory rate index within 3 days of high-flow nasal oxygen treatment. In a multivariate logistic regression analysis model, male and lower oxygen saturation at admission remained independent predictors of high-flow nasal oxygen failure. The hospital mortality rate of the cohort was 32.5%; however, the hospital mortality rate in patients with high-flow nasal oxygen failure was 65%.ConclusionsHigh-flow nasal oxygen may be effective for treating coronavirus disease 2019 patients with mild to moderate acute hypoxemic respiratory failure. However, high-flow nasal oxygen failure was associated with a poor prognosis. Male and lower oxygenation at admission were the two strong predictors of high-flow nasal oxygen failure.

Project description:PurposeTo report a French experience in patients admitted to Intensive Care Unit (ICU) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) requiring high fractional concentration of inspired oxygen supported by high flow nasal cannula (HFNC) as first-line therapy.MethodsRetrospective cohort study conducted in two ICUs of a French university hospital. All consecutive patients admitted during 28-days after the first admission for SARS-CoV-2 pneumonia were screened. Demographic, clinical, respiratory support, specific therapeutics, ICU length-of-stay and survival data were collected.ResultsData of 43 patients were analyzed: mainly men (72%), median age 61 (51-69) years, median body mass index of 28 (25-31) kg/m2, median simplified acute physiology score (SAPS II) of 29 (22-37) and median PaO2/fraction of inspired oxygen (FiO2) (P/F) ratio of 146 (100-189) mmHg. HFNC was initiated at ICU admission in 76% of patients. Median flow was 50 (45-50) L/min and median FiO2 was 0.6 (0.5-0.8). 79% of patients presented at least one comorbidity, mainly hypertension (58%). At day (D) 28, 32% of patients required invasive mechanical ventilation, 3 patients died in ICU. Risk factors for intubation were diabetes (10% vs. 43%, P=0.04) and extensive lesions on chest computed tomography (CT) (P=0.023). Patients with more than 25% of lesions on chest CT were more frequently intubated during ICU stay (P=0.012). At ICU admission (D1), patients with higher SAPS II and Sequential Organ Failure Assessment (SOFA) scores (respectively 39 (28-50) vs. 27 (22-31), P=0.0031 and 5 (2-8) vs. 2 (2-2.2), P=0.0019), and a lower P/F ratio (98 (63-109) vs. 178 (126-206), P=0.0005) were more frequently intubated. Among non-intubated patients, the median lowest P/F was 131 (85-180) mmHg. Four caregivers had to stop working following coronavirus 2 contamination, but did not require hospitalization.ConclusionOur clinical experience supports the use of HFNC as first line-therapy in patients with SARS-COV-2 pneumonia for whom face mask oxygen does not provide adequate respiratory support.

Project description:BackgroundWe performed a systematic review and meta-analysis to evaluate the efficacy and safety of high-flow oxygen via nasal cannulae (HFNC) compared to non-invasive ventilation (NIV) and/or standard oxygen in patients with acute, hypoxemic respiratory failure.MethodsWe reviewed randomized controlled trials from CENTRAL, EMBASE, MEDLINE, Scopus and the International Clinical Trials Registry Platform (inception to February 2016), conference proceedings, and relevant article reference lists. Two reviewers independently screened and extracted trial-level data from trials investigating HFNC in patients with acute, hypoxemic respiratory failure. Internal validity was assessed in duplicate using the Cochrane Risk of Bias tool. The strength of evidence was assessed in duplicate using the Grading of Recommendations Assessment, Development and Evaluation framework. Our primary outcome was mortality. Secondary outcomes included dyspnea, PaO2:FiO2 ratio, PaCO2, and pH. Safety outcomes included respiratory arrest, intubation, delirium, and skin breakdown.ResultsFrom 2023 screened citations, we identified seven trials (1771 patients) meeting inclusion criteria. All trials were at high risk of bias due to lack of blinding. There was no evidence for a mortality difference in patients receiving HFNC vs. NIV and/or standard oxygen (RR 1.01, 95% CI 0.69 to 1.48, I 2 = 63%, five trials, 1629 patients). In subgroup analyses of HFNC compared to NIV or standard oxygen individually, mortality differences were not observed. Measures of patient tolerability were heterogeneous. The PaO2:FiO2 ratio at 6-12 h was significantly lower in patients receiving oxygen via HFNC compared to NIV or standard oxygen for hypoxemic respiratory failure (MD - 53.34, 95% CI - 71.95 to - 34.72, I 2 = 61%, 1143 patients). There were no differences in pH, PaCO2, or rates of intubation or cardio-respiratory arrest. Delirium and skin breakdown were infrequently reported in included trials.ConclusionsIn patients with acute hypoxemic respiratory failure HFNC was not associated with a difference in mortality compared to NIV or standard oxygen. Secondary outcomes including dyspnea, tolerance, and safety were not systematically reported. Residual heterogeneity and variable reporting of secondary outcomes limit the conclusions that can be made in this review. Prospective trials designed to evaluate the efficacy and safety of HFNC in patients with acute hypoxemic respiratory failure are required.

Dataset Information

The Use of High-Flow Nasal Oxygen in the ICU as a First-Line Therapy for Acute Hypoxemic Respiratory Failure Secondary to Coronavirus Disease 2019.

Publications

The Use of High-Flow Nasal Oxygen in the ICU as a First-Line Therapy for Acute Hypoxemic Respiratory Failure Secondary to Coronavirus Disease 2019.

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