Failure of High Flow Nasal Cannula and Subsequent Intubation Is Associated With Increased Mortality as Compared to Failure of Non-Invasive Ventilation and Mechanical Ventilation Alone: A Real-World Retrospective Analysis

Abstract

Background: Despite the increasing use of high flow nasal cannula oxygenation systems (HFNC) in clinical practice, little is known about its role in all cause respiratory failure as compared to traditional non-invasive ventilation (BiPAP). Furthermore, the effect of HFNC on mortality is unknown. Methods: We conducted a retrospective analysis of 49,853 patients with respiratory failure treated with non-invasive respiratory support (HFNC or BiPAP) and/or invasive mechanical ventilation (IMV) between 2017 and 2018. Results: Patients initially treated with HFNC who underwent subsequent intubation and IMV had a higher mortality rate as compared to patients who were initially treated with BiPAP and underwent subsequent intubation and IMV (34.8% vs 26.3%, p < 0.0001, OR 1.49, 95% CI 1.26,1.76). Patients first treated with HFNC who underwent subsequent intubation and IMV had a significantly increased mortality compared to patients who underwent immediate intubation and IMV (34.8% vs. 21.5%, p ≤ 0.0001, OR 1.94, 95% CI 1.67, 2.27). Stratified based on ICD-10 diagnosis, patients with a diagnosis of COPD exacerbation or heart failure treated with HFNC and subsequent intubation and IMV had higher mortality as compared to those treated with immediate IMV alone. This trend did not hold true for patients with a diagnosis of pneumonia. Conclusion: In a real-world retrospective analysis, use of HFNC was associated with increased mortality as compared to BiPAP and IMV alone. Further study is needed to confirm these associations.

Implications of early respiratory support strategies on disease progression in critical COVID-19: a matched subanalysis of the prospective RISC-19-ICU cohort

“…In our study, this patient-induced biotrauma might be one of the factors explaining the pronounced CRP dynamics in the noninvasively supported groups as opposed to those receiving early IMV [38]. Consequently, the prolonged use of noninvasive ventilation, delaying intubation in patients who ultimate fail and thus require IMV, has been associated with higher mortality rates in ARDS [39][40][41][42][43], as well as in critically ill COVID-19 patients [44][45][46] [24,47].…”

Supplementation of High Velocity Nasal Insufflation with a Nonrebreather Mask for Severe Hypoxemic Respiratory Failure in Adult Patients with COVID-19

“…These findings were discussed at length in a review by Ricard, suggesting that confounding variables likely played a role in why the mortality rates reported in this paper seem more extreme than those reported in other studies [ 25 , 26 ]. The second study by Miller et al was a retrospective database analysis reporting that, amongst patients who failed primary therapy and later required mechanical ventilation, patients who had been primarily treated with HFNC had higher mortality than those treated with BiPaP [ 27 ]. Unfortunately, the sample sizes are extremely different (2,241 HFNC vs. 32,761 BiPaP), and the initial indications for treatment were not available for a majority of the patients in the HFNC group.…”

The use of respiration-oxygenation (ROX) index in determining high-flow nasal canula outcome in COVID-19 pneumonia

“…Determining when a patient is transferred from HFNC to a mechanical ventilator is still a challenge. the decision to intubate after more than 48 hours, compared to those intubated before 48 hours [10]. At presentation our patient had significant hypoxaemia and according to our hospital guidelines, HFNC was administered first to treat hypoxemia.…”