Combined Noninvasive Respiratory Support Therapies to Treat COVID-19

Abstract

BACKGROUND: The roles of high-flow nasal cannula (HFNC) and CPAP in coronavirus disease 2019 (COVID-19) are controversial. The objective of the study was to evaluate the impact of the application of a noninvasive respiratory support algorithm on clinical outcomes in subjects with COVID-19 and with acute respiratory failure. METHODS: We performed a singlecenter prospective observational study of subjects with respiratory failure from COVID-19 managed with HFNC and with CPAP plus HFNC (combined therapy). The main outcome was the intubation rate, which defined failure of therapy. We also analyzed the role of the ROX index ([S pO 2 /F IO 2 ]/breathing frequency) to predict the need for intubation. RESULTS: From June to December 2020, 113 subjects with COVID-19 respiratory failure were admitted to our respiratory intermediate care unit. HFNC was applied in 65 subjects (57.52%) and combined therapy in 48 subjects (42.47%). A total of 83 subjects (73.45%) were successfully treated with noninvasive respiratory support. The intubation rate was 26.54%, and the overall mortality rate was 14.15%. The mortality rate in subjects who were intubated was 55.2%. An ROX index of 6.28 at 12 h predicted noninvasive respiratory support failure, with 97.6% sensitivity and 51.8% specificity. CONCLUSIONS: Data from our cohort managed in a respiratory intermediate care unit showed that combined noninvasive respiratory support was feasible, with favorable outcomes. Further prospective studies are required.

Intubation Timing in COVID-19 Based on ROX Index and Association With Patient Outcomes

“…28 Subsequently, various investigators have studied the use of the ROX index in COVID-19 in different cohorts at varying times in the disease course, resulting in slightly different proposed cutoffs. In a cohort of 113 subjects treated with or without HFNC, Colaianni-Alfonso et al 29 report a ROX index score cutoff of # 6.28 after 12 h of treatment predicted failure of noninvasive therapy with sensitivity of 97.6% and specificity of 51.8%. In a cohort of 120 subjects, Vega et al 30 reported that, after 12 h of HFNC therapy, the optimal ROX cutoff was 5.99.…”

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

“…1 . In a trial of COVID-19 patients with acute hypoxic respiratory failure, 65 patients in the HFNC group had escalation to CPAP, with only 15% ultimately requiring intubation, while a second group of 48 patients utilizing an initial combined therapy of both HFNC and CPAP failed non-invasive methods with 42% requiring intubation [ 48 ]. Another study examined a non-invasive trial (delivered in this study using facemask and ventilator with positive pressure support and defined as NIV by the study authors) as rescue therapy if CPAP failed to avoid intubation, finding slightly lower mortality rates in patients who used a stepwise approach of CPAP, BPAP, and then endotracheal intubation (20%) versus CPAP followed by endotracheal intubation (22%) (Kaplan Meier overall survival probability P < 0.01) [ 49 ].…”

Non-invasive Respiratory Support in COVID-19: A Narrative Review

“…Both scenarios were retrospectively studied by Colaianni et al ( 66 ) in a clinical study conducted under a careful algorithm for managing ARF in COVID patients. The first step was HFOT and prone position.…”