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      Predictors of high flow oxygen therapy failure in COVID-19-related severe hypoxemic respiratory failure

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          Abstract

          Background

          During COVID-19 pandemic, people who developed pneumonia and needed supplemental oxygen, where treated with low-flow oxygen therapy systems and non-invasive methods, including oxygen therapy using high flow nasal cannula (HFNC) and the application of bi-level or continuous positive airway pressure (BiPAP or CPAP). We aimed to investigate the outcomes of critical COVID-19 patients treated with HFNC and unveil predictors of HFNC failure.

          Methods

          We retrospectively enrolled patients admitted to COVID-19 wards and treated with HFNC for COVID-19-related severe hypoxemic respiratory failure. The primary outcome of this study was treatment failure, such as the composite of intubation or death during hospital stay. The association between treatment failure and clinical features was evaluated using logistic regression models.

          Results

          One hundred thirty-two patients with a median (IQR) PaO 2/FiO 2 ratio 96 (63–173) mmHg at HFNC initiation were studied. Overall, 45.4% of the patients were intubated. Hospital mortality was 31.8%. Treatment failure (intubation or death) occurred in 50.75% and after adjustment for age, gender, Charlson Comorbidity index (CCI) score and National Early Warning Score 2 (NEWS2) score on admission and PaO 2/FiO 2 ratio and acute respiratory distress syndrome (ARDS) severity at the time of HFNO initiation, it was significantly associated with the presence of dyspnea [adjusted OR 2.48 (95% CI: 1.01–6.12)], and higher Urea serum levels [adjusted OR 1.25 (95% CI: 1.03–1.51) mg/dL].

          Conclusions

          HFNC treatment was successful in almost half of the patients with severe COVID-19-related acute hypoxemic respiratory failure (AHRF). The presence of dyspnea and high serum Urea levels on admission are closely related to HFNC failure.

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          Most cited references22

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          Acute respiratory distress syndrome: the Berlin Definition.

          V Ranieri, Gordon D Rubenfeld, B Taylor Thompson … (2013)
          The acute respiratory distress syndrome (ARDS) was defined in 1994 by the American-European Consensus Conference (AECC); since then, issues regarding the reliability and validity of this definition have emerged. Using a consensus process, a panel of experts convened in 2011 (an initiative of the European Society of Intensive Care Medicine endorsed by the American Thoracic Society and the Society of Critical Care Medicine) developed the Berlin Definition, focusing on feasibility, reliability, validity, and objective evaluation of its performance. A draft definition proposed 3 mutually exclusive categories of ARDS based on degree of hypoxemia: mild (200 mm Hg < PaO2/FIO2 ≤ 300 mm Hg), moderate (100 mm Hg < PaO2/FIO2 ≤ 200 mm Hg), and severe (PaO2/FIO2 ≤ 100 mm Hg) and 4 ancillary variables for severe ARDS: radiographic severity, respiratory system compliance (≤40 mL/cm H2O), positive end-expiratory pressure (≥10 cm H2O), and corrected expired volume per minute (≥10 L/min). The draft Berlin Definition was empirically evaluated using patient-level meta-analysis of 4188 patients with ARDS from 4 multicenter clinical data sets and 269 patients with ARDS from 3 single-center data sets containing physiologic information. The 4 ancillary variables did not contribute to the predictive validity of severe ARDS for mortality and were removed from the definition. Using the Berlin Definition, stages of mild, moderate, and severe ARDS were associated with increased mortality (27%; 95% CI, 24%-30%; 32%; 95% CI, 29%-34%; and 45%; 95% CI, 42%-48%, respectively; P < .001) and increased median duration of mechanical ventilation in survivors (5 days; interquartile [IQR], 2-11; 7 days; IQR, 4-14; and 9 days; IQR, 5-17, respectively; P < .001). Compared with the AECC definition, the final Berlin Definition had better predictive validity for mortality, with an area under the receiver operating curve of 0.577 (95% CI, 0.561-0.593) vs 0.536 (95% CI, 0.520-0.553; P < .001). This updated and revised Berlin Definition for ARDS addresses a number of the limitations of the AECC definition. The approach of combining consensus discussions with empirical evaluation may serve as a model to create more accurate, evidence-based, critical illness syndrome definitions and to better inform clinical care, research, and health services planning.
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            Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19): A Review

            W. Joost Wiersinga, Andrew Rhodes, Allen Cheng … (2020)
            The coronavirus disease 2019 (COVID-19) pandemic, due to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused a worldwide sudden and substantial increase in hospitalizations for pneumonia with multiorgan disease. This review discusses current evidence regarding the pathophysiology, transmission, diagnosis, and management of COVID-19.
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              High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure.

              Jean-Pierre Frat, Arnaud W Thille, Alain Mercat … (2015)
              Whether noninvasive ventilation should be administered in patients with acute hypoxemic respiratory failure is debated. Therapy with high-flow oxygen through a nasal cannula may offer an alternative in patients with hypoxemia.
              Article 0 comments Cited 475 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Thorac Dis
                Journal ID (iso-abbrev): J Thorac Dis
                Journal ID (publisher-id): JTD
                Title: Journal of Thoracic Disease
                Publisher: AME Publishing Company
                ISSN (Print): 2072-1439
                ISSN (Electronic): 2077-6624
                Publication date (Print and electronic): April 2022
                Publication date (Print): April 2022
                Volume: 14
                Issue: 4
                Pages: 851-856
                Affiliations
                [1 ]deptCOVID-19 Unit , “Evaggelismos” General Hospital , Athens, Greece;
                [2 ]1st Department of Critical Care and Pulmonary Medicine, National and Kapodistrian University of Athens, Evaggelismos Hospital , Athens, Greece;
                [3 ]deptPulmonary Department , Evaggelismos Hospital , Athens, Greece;
                [4 ]deptInstitute of Health Informatics , University College London , London, UK
                Author notes

                Contributions: (I) Conception and design: I Kalomenidis; (II) Administrative support: M Katsoulis; (III) Provision of study materials or patients: E Polydora, M Alexandrou, S Tsipilis, N Athanasiou, A Rodopoulou; (IV) Collection and assembly of data: E Polydora, M Alexandrou, S Tsipilis, N Athanasiou, A Rodopoulou; (V) Data analysis and interpretation: I Kalomenidis, A Pappas, M Katsoulis, M Alexandrou; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

                Correspondence to: Eftychia Polydora, MD. Evaggelismos Hospital, 45-47 Ipsilandou street, 10676 Athens, Greece. Email: felicitypol@ 123456gmail.com .
                Article
                Publisher ID: jtd-14-04-851
                DOI: 10.21037/jtd-21-1373
                PMC ID: 9096326
                PubMed ID: 35572875
                SO-VID: 5cab6991-4a59-4b27-b060-0e6861caac65
                Copyright © 2022 Journal of Thoracic Disease. All rights reserved.
                License:

                Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0.

                History
                Date received : 20 August 2021
                Date accepted : 21 January 2022
                Categories
                Subject: Original Article

                Keywords: covid-19,acute respiratory distress syndrome (ards),respiratory failure,high flow nasal cannula (hfnc),intubation
                Data availability:
                Keywords: covid-19, acute respiratory distress syndrome (ards), respiratory failure, high flow nasal cannula (hfnc), intubation

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