Effect of High-Flow Oxygen Therapy vs Conventional Oxygen Therapy on Invasive Mechanical Ventilation and Clinical Recovery in Patients With Severe COVID-19

Abstract

IMPORTANCEThe effect of high-flow oxygen therapy vs conventional oxygen therapy has not been established in the setting of severe COVID-19.OBJECTIVE To determine the effect of high-flow oxygen therapy through a nasal cannula compared with conventional oxygen therapy on need for endotracheal intubation and clinical recovery in severe COVID-19. DESIGN, SETTING, AND PARTICIPANTSRandomized, open-label clinical trial conducted in emergency and intensive care units in 3 hospitals in Colombia. A total of 220 adults with respiratory distress and a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen of less than 200 due to COVID-19 were randomized from August 2020 to January 2021, with last follow-up on February 10, 2021.INTERVENTIONS Patients were randomly assigned to receive high-flow oxygen through a nasal cannula (n = 109) or conventional oxygen therapy (n = 111). MAIN OUTCOMES AND MEASURESThe co-primary outcomes were need for intubation and time to clinical recovery until day 28 as assessed by a 7-category ordinal scale (range, 1-7, with higher scores indicating a worse condition). Effects of treatments were calculated with a Cox proportional hazards model adjusted for hypoxemia severity, age, and comorbidities. RESULTS Among 220 randomized patients, 199 were included in the analysis (median age, 60 years; n = 65 women [32.7%]). Intubation occurred in 34 (34.3%) randomized to high-flow oxygen therapy and in 51 (51.0%) randomized to conventional oxygen therapy (hazard ratio, 0.62; 95% CI, 0.39-0.96; P = .03). The median time to clinical recovery within 28 days was 11 (IQR, 9-14) days in patients randomized to high-flow oxygen therapy vs 14 (IQR,(11)(12)(13)(14)(15)(16)(17)(18)(19) days in those randomized to conventional oxygen therapy (hazard ratio, 1.39; 95% CI, 1.00-1.92; P = .047). Suspected bacterial pneumonia occurred in 13 patients (13.1%) randomized to high-flow oxygen and in 17 (17.0%) of those randomized to conventional oxygen therapy, while bacteremia was detected in 7 (7.1%) vs 11 (11.0%), respectively.CONCLUSIONS AND RELEVANCE Among patients with severe COVID-19, use of high-flow oxygen through a nasal cannula significantly decreased need for mechanical ventilation support and time to clinical recovery compared with conventional low-flow oxygen therapy.

Clinical characteristics, systemic complications, and in-hospital outcomes for patients with COVID-19 in Latin America. LIVEN-Covid-19 study: A prospective, multicenter, multinational, cohort study

“…Our study also found that shortness of breath and elevated serum concentrations of lactate were independently associated with ICU admission. This is concordant with what is reported in the literature, as only severe COVID-19 patients are admitted to ICU [ 32 , 33 ]. These factors are essential because they are easily identifiable by physicians on hospital admission and might guide them to early detection of patients at risk of developing severe disease.…”

Airborne SARS-CoV-2 RNA excretion by patients with COVID-19 on different oxygen-delivery systems: a prospective observational study

“…Concerns however persist on their potential aggravating role in airborne Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2) transmission. High-Flow Nasal Cannula (HFNC) oxygen therapy appears clinically beneficial for patients with COVID-19 but was discouraged earlier in the pandemic because of its aerosol-generating potential [ 1 , 2 ]. Accumulating non-clinical data indicate that HFNC is not associated with more dispersion of aerosols and large droplets compared to conventional oxygen delivery systems [ 3 ].…”

Clinical update on COVID-19 for the emergency clinician: Airway and resuscitation

“…A later meta-analysis found HFNC reduced intubation rates compared to NIPPV (OR 0.48, 95% CI 0.31–0.73), as well as ICU mortality (OR 0.36, 95% 0.20–0.63) [ 33 ]. A randomized controlled trial (RCT) of patients with PaO 2 /FiO 2 < 200 and COVID-19 found those receiving HFNC were less likely to be intubated (34.3% vs. 51%) and more likely to experience clinical recovery in 28 days (77.8% vs. 71%) compared to those receiving conventional oxygen [ 34 ].…”