High Failure Rate of Noninvasive Oxygenation Strategies in Critically Ill Subjects With Acute Hypoxemic Respiratory Failure Due to COVID-19

Abstract

BACKGROUND: The efficacy of noninvasive oxygenation strategies (NIOS) in treating COVID-19 disease is unknown. We conducted a prospective observational study to assess the rate of NIOS failure in subjects treated in the ICU for hypoxemic respiratory failure due to COVID-19. METHODS: Patients receiving first-line treatment NIOS for hypoxemic respiratory failure due to COVID-19 in the ICU of a university hospital were included in this study; laboratory data were collected upon arrival, and 28-d outcome was recorded. After propensity score matching based on Simplified Acute Physiology (SAPS) II score, age, P aO 2 =F IO 2 and P aCO 2 at arrival, the NIOS failure rate in subjects with COVID-19 was compared to a previously published cohort who received NIOS during hypoxemic respiratory failure due to other causes. RESULTS: A total of 85 subjects received first-line treatment with NIOS. The most frequently used methods were helmet noninvasive ventilation and highflow nasal cannula; of these, 52 subjects (61%) required endotracheal intubation. Independent factors associated with NIOS failure were SAPS II score (P 5 .009) and serum lactate dehydrogenase at enrollment (P 5 .02); the combination of SAPS II score 6 33 with serum lactate dehydrogenase 6 405 units/L at ICU admission had 91% specificity in predicting the need for endotracheal intubation. In the propensity-matched cohorts (54 pairs), subjects with COVID-19 showed higher risk of NIOS failure than those with other causes of hypoxemic respiratory failure (59% vs 35%, P 5 .02), with an adjusted hazard ratio of 2 (95% CI 1.1-3.6, P 5 .01). CONCLUSIONS: As compared to hypoxemic respiratory failure due to other etiologies, subjects with COVID-19 who were treated with NIOS in the ICU were burdened by a 2-fold higher risk of failure. Subjects with a SAPS II score 6 33 and serum lactate dehydrogenase 6 405 units/L represent the population with the greatest risk.

Dyspnoea and clinical outcome in critically ill patients receiving noninvasive support for COVID-19 respiratory failure: post hoc analysis of a randomised clinical trial

“…Presence of moderate-to-severe dyspnea might be a marker of disease severity correlated to outcomes, possibly configuring a clinical sub-phenotype of COVID-19 severe respiratory failure. Use of noninvasive support in COVID-19 patients is common [9][10][11][12]. While considering a trial of noninvasive respiratory support in COVID-19 patients with moderate-to-severe respiratory failure, the presence of dyspnea, measured during conventional oxygen therapy, in conjunction with other variables such as respiratory rate and degree of hypoxia may represent a simple alert tool to identify patients with the highest risk of endotracheal intubation.…”

High flow nasal cannula for adult acute hypoxemic respiratory failure in the ED setting

“…The current evidence demonstrates HFNC is safe and reduces the need for intubation in COVID-19 without clear mortality benefit [ [37] , [38] , [39] , [40] , [41] , [42] , [43] ]. However, high failure rates have been observed with NIPPV and HFNC in COVID-19, with one study finding 61% of patients required endotracheal intubation [ 44 ]; close monitoring for signs of failure is warranted.…”

The use of head helmets to deliver noninvasive ventilatory support: a comprehensive review of technical aspects and clinical findings

“…Patients with coronavirus disease 2019 (COVID-19) pneumonia can develop severe hypoxemia and require PEEP, although these patients are at greater risk of NIV failure than patients with ARF with other aetiologies [ 28 ]. Some authors have suggested that helmets might reduce aerosol spread [ 29 , 30 ], as confirmed by some exploratory studies [ 31 , 32 ].…”