Effect of Noninvasive Respiratory Strategies on Intubation or Mortality Among Patients With Acute Hypoxemic Respiratory Failure and COVID-19

Abstract

IMPORTANCE Continuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) have been recommended for acute hypoxemic respiratory failure in patients with COVID-19. Uncertainty exists regarding the effectiveness and safety of these noninvasive respiratory strategies. OBJECTIVE To determine whether either CPAP or HFNO, compared with conventional oxygen therapy, improves clinical outcomes in hospitalized patients with COVID-19-related acute hypoxemic respiratory failure. DESIGN, SETTING, AND PARTICIPANTS A parallel group, adaptive, randomized clinical trial of 1273 hospitalized adults with COVID-19-related acute hypoxemic respiratory failure. The trial was conducted between April 6, 2020, and May 3, 2021, across 48 acute care hospitals in the UK and Jersey. Final follow-up occurred on June 20, 2021. INTERVENTIONS Adult patients were randomized to receive CPAP (n = 380), HFNO (n = 418), or conventional oxygen therapy (n = 475). MAIN OUTCOMES AND MEASURESThe primary outcome was a composite of tracheal intubation or mortality within 30 days. RESULTSThe trial was stopped prematurely due to declining COVID-19 case numbers in the UK and the end of the funded recruitment period. Of the 1273 randomized patients (mean age, 57.4 [95% CI, 56.7 to 58.1] years; 66% male; 65% White race), primary outcome data were available for 1260. Crossover between interventions occurred in 17.1% of participants (15.3% in the CPAP group, 11.5% in the HFNO group, and 23.6% in the conventional oxygen therapy group). The requirement for tracheal intubation or mortality within 30 days was significantly lower with CPAP (36.3%; 137 of 377 participants) vs conventional oxygen therapy (44.4%; 158 of 356 participants) (absolute difference, −8% [95% CI, −15% to −1%], P = .03), but was not significantly different with HFNO (44.3%; 184 of 415 participants) vs conventional oxygen therapy (45.1%; 166 of 368 participants) (absolute difference, −1% [95% CI, −8% to 6%], P = .83). Adverse events occurred in 34.2% (130/380) of participants in the CPAP group, 20.6% (86/418) in the HFNO group, and 13.9% (66/475) in the conventional oxygen therapy group.CONCLUSIONS AND RELEVANCE Among patients with acute hypoxemic respiratory failure due to COVID-19, an initial strategy of CPAP significantly reduced the risk of tracheal intubation or mortality compared with conventional oxygen therapy, but there was no significant difference between an initial strategy of HFNO compared with conventional oxygen therapy. The study may have been underpowered for the comparison of HFNO vs conventional oxygen therapy, and early study termination and crossover among the groups should be considered when interpreting the findings.

Epidemiological Characteristics and Severity of Omicron Variant Cases in the Aphp Critical Care Units

“…However, Omicron patients were still less invasively ventilated than Delta cases, which could be explained by still more immunocompromised patients. 10 Among patients admitted for pneumonia, we noted a relatively low rate of invasive ventilation (40-50% of cases), which could be explained first because ICUs in the APHP group usually include a mix of full ICU beds and of intermediate beds for less critically ill patients, and second because compared to the first wave, some studies have now suggested the beneficial effect of high-flow oxygen saturation 14,15 and non-invasive ventilation 16 on the requirement for invasive ventilation and on recovery, which probably led to changes in practices.…”

Non-invasive ventilation using a novel ventilator and non-vented full-face mask for patients with respiratory failure during the COVID-19 pandemic: Report of three cases

“…First, only one patient was a true COVID-19 patient. Nevertheless, recent large-scale data have supported NIV as a significantly useful method for patients with COVID-19 [ 7 , 10 ]. Second, since the machine used was a new machine for patients with COVID-19, it might have a negative effect in supporting patients’ breathing, such as high circuit resistance, difficulty in patient synchronization, and loss of humidity.…”

Mechanical Ventilation for COVID-19 Patients

“…More recently, Perkins et al conducted an adaptive, multicenter, randomized-controlled trial (RCT) to compare CPAP, HFNO, and conventional oxygen therapy in terms of tracheal intubation or 30-day mortality (composite outcome). 34 A total of 1,272 hospitalized patients with COVID- Mechanical Ventilation for COVID-19 Patients Brioni et al…”