Open AccessHigh-Flow Nasal Oxygen for Severe Hypoxemia: Oxygenation Response and Outcome in Patients with COVID-19
Author(s) -
V. Marco Ranieri,
Tommaso Tonetti,
Paolo Navalesi,
Stefano Nava,
Massimo Antonelli,
Antonio Artigas,
Domenico Luca Grieco,
Luca Salvatore Menga,
Lara Pisani,
Annalisa Boscolo,
Nicolò Sella,
Laura Pasin,
Chiara Mega,
Giacinto Pizzilli,
Alessio Dell’Olio,
Roberto Dongilli,
Paola Rucci,
Arthur S. Slutsky
Publication year - 2022
Publication title -
american journal of respiratory and critical care medicine
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 6.272
H-Index - 374
eISSN - 1535-4970
pISSN - 1073-449X
DOI - 10.1164/rccm.202109-2163oc
Subject(s) - ards , medicine , covid-19 , noninvasive ventilation , hypoxemia , intubation , ventilation (architecture) , mechanical ventilation , respiratory distress , anesthesia , acute respiratory distress , lung , disease , infectious disease (medical specialty) , mechanical engineering , engineering
Rationale: The "Berlin definition" of acute respiratory distress syndrome (ARDS) does not allow inclusion of patients receiving high-flow nasal oxygen (HFNO). However, several articles have proposed that criteria for defining ARDS should be broadened to allow inclusion of patients receiving HFNO. Objectives: To compare the proportion of patients fulfilling ARDS criteria during HFNO and soon after intubation, and 28-day mortality between patients treated exclusively with HFNO and patients transitioned from HFNO to invasive mechanical ventilation (IMV). Methods: From previously published studies, we analyzed patients with coronavirus disease (COVID-19) who had Pa O 2 /Fi O 2 of ⩽300 while treated with ⩾40 L/min HFNO, or noninvasive ventilation (NIV) with positive end-expiratory pressure of ⩾5 cm H 2 O (comparator). In patients transitioned from HFNO/NIV to invasive mechanical ventilation (IMV), we compared ARDS severity during HFNO/NIV and soon after IMV. We compared 28-day mortality in patients treated exclusively with HFNO/NIV versus patients transitioned to IMV. Measurements and Main Results: We analyzed 184 and 131 patients receiving HFNO or NIV, respectively. A total of 112 HFNO and 69 NIV patients transitioned to IMV. Of those, 104 (92.9%) patients on HFNO and 66 (95.7%) on NIV continued to have Pa O 2 /Fi O 2 ⩽300 under IMV. Twenty-eight-day mortality in patients who remained on HFNO was 4.2% (3/72), whereas in patients transitioned from HFNO to IMV, it was 28.6% (32/112) ( P < 0.001). Twenty-eight-day mortality in patients who remained on NIV was 1.6% (1/62), whereas in patients who transitioned from NIV to IMV, it was 44.9% (31/69) ( P < 0.001). Overall mortality was 19.0% (35/184) and 24.4% (32/131) for HFNO and NIV, respectively ( P = 0.2479). Conclusions: Broadening the ARDS definition to include patients on HFNO with Pa O 2 /Fi O 2 ⩽300 may identify patients at earlier stages of disease but with lower mortality.