Non-invasive oxygenation support in acutely hypoxemic COVID-19 patients admitted to the ICU: a multicenter observational retrospective study

Abstract

Background Non-invasive oxygenation strategies have a prominent role in the treatment of acute hypoxemic respiratory failure during the coronavirus disease 2019 (COVID-19). While the efficacy of these therapies has been studied in hospitalized patients with COVID-19, the clinical outcomes associated with oxygen masks, high-flow oxygen therapy by nasal cannula and non-invasive mechanical ventilation in critically ill intensive care unit (ICU) patients remain unclear. Methods In this retrospective study, we used the best of nine covariate balancing algorithms on all baseline covariates in critically ill COVID-19 patients supported with > 10 L of supplemental oxygen at one of the 26 participating ICUs in Catalonia, Spain, between March 14 and April 15, 2020. Results Of the 1093 non-invasively oxygenated patients at ICU admission treated with one of the three stand-alone non-invasive oxygenation strategies, 897 (82%) required endotracheal intubation and 310 (28%) died during the ICU stay. High-flow oxygen therapy by nasal cannula (n = 439) and non-invasive mechanical ventilation (n = 101) were associated with a lower rate of endotracheal intubation (70% and 88%, respectively) than oxygen masks (n = 553 and 91% intubated), p < 0.001. Compared to oxygen masks, high-flow oxygen therapy by nasal cannula was associated with lower ICU mortality (hazard ratio 0.75 [95% CI 0.58–0.98), and the hazard ratio for ICU mortality was 1.21 [95% CI 0.80–1.83] for non-invasive mechanical ventilation. Conclusion In critically ill COVID-19 ICU patients and, in the absence of conclusive data, high-flow oxygen therapy by nasal cannula may be the approach of choice as the primary non-invasive oxygenation support strategy.

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

“…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 .…”

“…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).…”

“…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.…”

“…The patients were admitted to different hospital settings and received noninvasive respiratory support at the time of admission. In 4 studies, 11 , 17 , 20 , 25 a helmet was applied, in 11 studies, 9 , 13 – 15 , 18 , 19 , 26 , 28 , 29 , 30 , 32 a face mask was used, 1 study 22 reported applying both a helmet and a face mask, 7 studies 12 , 16 , 21 , 23 , 24 , 27 , 31 did not report whether a helmet or a facemask was used, in 6 studies, 9 , 20 , 22 , 24 , 27 , 29 BiPAP was applied, 7 studies 11 , 17 – 19 , 25 , 26 , 30 featured CPAP, 4 studies 14 – 16 , 23 reported applying both BiPAP and CPAP, and 6 studies 12 , 13 , 21 , 28 , 31 , 32 did not report whether they applied BiPAP or CPAP ( Table 1…”

Dynamics of disease characteristics and clinical management of critically ill COVID-19 patients over the time course of the pandemic: an analysis of the prospective, international, multicentre RISC-19-ICU registry

“…Additionally, increasing experience in the treatment of acute hypoxemic respiratory failure due to COVID-19 in hospital wards including more advanced non-invasive respiratory support strategies and the progressive use of awake prone positioning might have postponed or completely avoided ICU admission [ 8 , 29 , 30 ]. This time lag could also explain the more pronounced hypoxemia and higher dead space at ICU admission in the later months of the pandemic possibly induced by patient self-inflicted lung injury (P-SILI) and contrasting with the lower overall severity scores [ 12 , 31 ]. Furthermore, as previously mentioned, early initiation of dexamethasone and remdesivir, but also the increasing use of intermediate and therapeutic anticoagulation after the first wave might be responsible for the delayed ICU admission [ 4 , 5 , 23 ].…”