Late Failure of High-Flow Nasal Cannula May Be Associated with High Mortality in COVID-19 Patients: A Multicenter Retrospective Study in the Republic of Korea

Abstract

The aim of this study was to determine whether the late failure of high-flow nasal cannula (HFNC) is associated with mortality in patients with coronavirus disease 2019 (COVID-19). This multicenter study included seven university-affiliated hospitals in the Republic of Korea. We collected the data of patients hospitalized with COVID-19 between 10 February 2020 and 28 February 2021. Failure of HFNC was defined as the need for mechanical ventilation despite HFNC application. According to the time of intubation, HFNC failure was divided into early failure (within 48 h) and late failure (after 48 h). During the study period, 157 patients received HFNC and 133 were eligible. Among them, 70 received mechanical ventilation. The median time from HFNC initiation to intubation of the early failure group was 4.1 h (interquartile range [IQR]: 1.1–13.5 h), and that of the late failure group was 70.9 h (IQR: 54.4–145.4 h). Although the ratio of pulse oximetry/fraction of inspired oxygen (ROX index) within 24 h of HFNC initiation tended to be lower in the early failure group than in the late failure group, the ROX index before two hours of intubation was significantly lower in the late failure group (odds ratio [OR], 5.74 [IQR: 4.58–6.98] vs. 4.80 [IQR: 3.67–5.97], p = 0.040). The late failure of HFNC may be associated with high mortality in COVID-19 patients with acute respiratory failure.

Validation of Sequential ROX-Index Score Beyond 12 Hours in Predicting Treatment Failure and Mortality in COVID-19 Patients Receiving Oxygen via High-Flow Nasal Cannula

“…Our analysis included all the previously stated factors as well as the HFNC treatment duration and the SOFA score. Consistent with previous studies' findings, patients' age and SOFA score were shown to increase along with the mortality as independent risk factors [ 19 , 20 ]. This finding indicates that using the SOFA score could help clinicians make rationalized and safe decisions during the management of hypoxemic COVID-19 patients outside the ICU.…”

“…Patients that met the primary outcome had a median time under HFNC of 6 (4-8) days and median total duration of stay in-hospital of 15 (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)days. In contrast, patients that did not meet the primary endpoint stayed 3 (1-6) days under HFNC, a fnding that met statistical signifcance (p < 0.001) compared to the primary endpoint group, while there was no diference in total duration of hospitalization with a median time of 16 (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27) days. Amongst patients successfully de-escalated, there was a signifcant correlation between the ROXindex and the number of days spent under HFNC (Spearman r � −0.256 and p � 0.044).…”

Delayed mechanical ventilation with prolonged high-flow nasal cannula exposure time as a risk factor for mortality in acute respiratory distress syndrome due to SARS-CoV-2

“…This group also had disadvantages in terms of extubation timing and ventilator-free days [ 20 ]. Baek reported similar findings in COVID-19 patients [ 35 ], with mortality at 38% for early HFNC failure and 65% for late HFNC failure ( p : 0.041).…”

“…95%CI 0.80-5.62. p: 0.13), regardless of the exposure time. Baek [35] reported similar findings (adjusted OR 4.75. 95% CI 1.118-20.236. p: 0.035).…”

“…This group also had disadvantages in terms of extubation timing and ventilator-free days [20]. Baek reported similar findings in COVID-19 patients [35], with mortality at 38% for early HFNC failure and 65% for late HFNC failure (p: 0.041). Data in the present study suggest that mortality increases with a delayed switch to IMV after a prolonged time in HFNC.…”