High-Flow Nasal Oxygen for Severe Hypoxemia: Oxygenation Response and Outcome in Patients with COVID-19

Ranieri, V. Marco; Tonetti, Tommaso; Navalesi, Paolo; Nava, Stefano; Antonelli, Massimo; Artigas, Antonio; Grieco, Domenico Luca; Menga, Luca Salvatore; Pisani, Lara; Boscolo, Annalisa; Sella, Nicolò; Pasin, Laura; Mega, Chiara; Pizzilli, Giacinto; Dell’Olio, Alessio; Dongilli, Roberto; Rucci, Paola; Slutsky, Arthur S.

doi:10.1164/rccm.202109-2163oc

Cited by 45 publications

(47 citation statements)

References 35 publications

(62 reference statements)

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“…After excluding duplicates and evaluating the full texts of articles, we identified 23 eligible studies 9 , 11 – 32 (3 RCTs, 20 , 24 , 26 8 prospective observational studies, 13 , 16 , 18 , 19 , 22 , 25 , 28 , 30 and 12 retrospective observational studies). 9 , 11 , 12 , 14 , 15 , 17 , 21 , 23 , 27 , 29 , 31 , 32 The process of searching and screening is described in Figure 1 . The main characteristics of the articles included in the meta-analysis are shown in Table 1 .…”

Section: Resultsmentioning

confidence: 99%

“…Two studies were considered to have an unclear risk of bias. The 20 observational 9 , 11 – 19 , 21 – 23 , 25 , 27 – 32 studies were assessed using the NOS checklist, and the results are shown in the Table 2 . All studies were of medium quality (⩾5 stars) or above, and 10 were considered high quality (⩾8 stars).…”

Section: Resultsmentioning

confidence: 99%

“…A total of 5354 patients participated in the 23 studies 9 , 11 – 32 of the present meta-analysis, all of whom were adult COVID-19 patients. The patients were admitted to different hospital settings and received noninvasive respiratory support at the time of admission.…”

Section: Resultsmentioning

confidence: 99%

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Comparison between high-flow nasal cannula and noninvasive ventilation in COVID-19 patients: a systematic review and meta-analysis

Peng

Dai

Zhao

et al. 2022

Ther Adv Respir Dis

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Background: High-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) are important treatment approaches for acute hypoxemic respiratory failure (AHRF) in coronavirus disease 2019 (COVID-19) patients. However, the differential impact of HFNC versus NIV on clinical outcomes of COVID-19 is uncertain. Objectives: We assessed the effects of HFNC versus NIV (interface or mode) on clinical outcomes of COVID-19. Methods: We searched PubMed, EMBASE, Web of Science, Scopus, MedRxiv, and BioRxiv for randomized controlled trials (RCTs) and observational studies (with a control group) of HFNC and NIV in patients with COVID-19-related AHRF published in English before February 2022. The primary outcome of interest was the mortality rate, and the secondary outcomes were intubation rate, PaO2/FiO2, intensive care unit (ICU) length of stay (LOS), hospital LOS, and days free from invasive mechanical ventilation [ventilator-free day (VFD)]. Results: In all, 23 studies fulfilled the selection criteria, and 5354 patients were included. The mortality rate was higher in the NIV group than the HFNC group [odds ratio (OR) = 0.66, 95% confidence interval (CI): 0.51–0.84, p = 0.0008, I2 = 60%]; however, in this subgroup, no significant difference in mortality was observed in the NIV-helmet group (OR = 1.21, 95% CI: 0.63–2.32, p = 0.57, I2 = 0%) or NIV-continuous positive airway pressure (CPAP) group (OR = 0.77, 95% CI: 0.51–1.17, p = 0.23, I2 = 65%) relative to the HFNC group. There were no differences in intubation rate, PaO2/FiO2, ICU LOS, hospital LOS, or days free from invasive mechanical ventilation (VFD) between the HFNC and NIV groups. Conclusion: Although mortality was lower with HFNC than NIV, there was no difference in mortality between HFNC and NIV on a subgroup of helmet or CPAP group. Future large sample RCTs are necessary to prove our findings. Registration: This systematic review and meta-analysis protocol was prospectively registered with PROSPERO (no. CRD42022321997).

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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Comparison between high-flow nasal cannula and noninvasive ventilation in COVID-19 patients: a systematic review and meta-analysis

Peng

Dai

Zhao

et al. 2022

Ther Adv Respir Dis

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“…However, despite lacking clinical evidence, ARDS criteria have been applied to patients not undergoing invasive mechanical ventilation [ 9 ]. Recent reports have indicated some applicability of a low PaO 2 /F I O 2 ratio during HFNC to predict mortality [ 10 ]. The main aim of the current study was to allow the accurate stratification of respiratory dysfunction during HFNC and NIV in COVID-19 ARDS patients by providing expected differences in PaO 2 /F I O 2 ratio upon a change in ventilatory strategy.…”

Section: Introductionmentioning

confidence: 99%

Limitations of the ARDS criteria during high-flow oxygen or non-invasive ventilation: evidence from critically ill COVID-19 patients

et al. 2022

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Background The ratio of partial pressure of arterial oxygen to inspired oxygen fraction (PaO2/FIO2) during invasive mechanical ventilation (MV) is used as criteria to grade the severity of respiratory failure in acute respiratory distress syndrome (ARDS). During the SARS-CoV2 pandemic, the use of PaO2/FIO2 ratio has been increasingly used in non-invasive respiratory support such as high-flow nasal cannula (HFNC) and non-invasive ventilation (NIV). The grading of hypoxemia in non-invasively ventilated patients is uncertain. The main hypothesis, investigated in this study, was that the PaO2/FIO2 ratio does not change when switching between MV, NIV and HFNC. Methods We investigated respiratory function in critically ill patients with COVID-19 included in a single-center prospective observational study of patients admitted to the intensive care unit (ICU) at Uppsala University Hospital in Sweden. In a steady state condition, the PaO2/FIO2 ratio was recorded before and after any change between two of the studied respiratory support techniques (i.e., HFNC, NIV and MV). Results A total of 148 patients were included in the present analysis. We find that any change in respiratory support from or to HFNC caused a significant change in PaO2/FIO2 ratio. Changes in respiratory support between NIV and MV did not show consistent change in PaO2/FIO2 ratio. In patients classified as mild to moderate ARDS during MV, the change from HFNC to MV showed a variable increase in PaO2/FIO2 ratio ranging between 52 and 140 mmHg (median of 127 mmHg). This made prediction of ARDS severity during MV from the apparent ARDS grade during HFNC impossible. Conclusions HFNC is associated with lower PaO2/FIO2 ratio than either NIV or MV in the same patient, while NIV and MV provided similar PaO2/FIO2 and thus ARDS grade by Berlin definition. The large variation of PaO2/FIO2 ratio indicates that great caution should be used when estimating ARDS grade as a measure of pulmonary damage during HFNC.

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“…In this issue of the Journal , Ranieri and colleagues (pp. 431–439 ) provide new data to help inform this discussion ( 13 ). Ranieri and colleagues analyzed outcomes of patients with COVID-19 pneumonia from four Italian studies, including three observational and one interventional study.…”

mentioning

confidence: 99%

Go with the Flow: Expanding the Definition of Acute Respiratory Distress Syndrome to Include High-Flow Nasal Oxygen

Ware

2022

Am J Respir Crit Care Med

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High-Flow Nasal Oxygen for Severe Hypoxemia: Oxygenation Response and Outcome in Patients with COVID-19

Cited by 45 publications

References 35 publications

Comparison between high-flow nasal cannula and noninvasive ventilation in COVID-19 patients: a systematic review and meta-analysis

Comparison between high-flow nasal cannula and noninvasive ventilation in COVID-19 patients: a systematic review and meta-analysis

Limitations of the ARDS criteria during high-flow oxygen or non-invasive ventilation: evidence from critically ill COVID-19 patients

Go with the Flow: Expanding the Definition of Acute Respiratory Distress Syndrome to Include High-Flow Nasal Oxygen

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