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For nearly 2 years, we have debated the best way to support patients with severe COVID-19 and hypoxemic respiratory failure. Despite initial concern that high-flow nasal cannula (HFNC) increased aerosolization of virus and put healthcare workers at greater risk, patients have been treated safely with HFNC in healthcare centers across the U.S. One remaining question is whether support with HFNC helps prevent subsequent intubation and mechanical ventilation.
Investigators from Colombia randomized nearly 200 patients with COVID-19 and acute hypoxemic respiratory failure (ratio of partial pressure of oxygen to fraction of inspired oxygen [PaO2:FiO2], <200) to either conventional oxygen therapy or HFNC within 30 minutes of randomization. Patients who warranted immediate intubation or had significant hypercarbia were excluded. Decisions about intubation and extubation were protocolized and did not allow crossover to HFNC from conventional oxygen. Almost all patients received steroids, and cumulative awake self-proning time was similar between groups.
Fewer patients treated with HFNC required intubation and invasive mechanical ventilation (34% vs. 51%), and median time to recovery was 3 days shorter in the HFNC group. Adverse events, hospital length of stay, and mortality were similar between groups.
Ospina-Tascón GA et al. Effect of high-flow oxygen therapy vs conventional oxygen therapy on invasive mechanical ventilation and clinical recovery in patients with severe COVID-19: A randomized clinical trial. JAMA 2021 Dec 7; 326:2161. (https://doi.org/10.1001/jama.2021.20714)
Comment
Avoiding intubation is an important, patient-centered outcome. Patients who require mechanical ventilation are at risk for many nosocomial complications — from delirium to ventilator-associated pneumonia. In most hospitals, hypoxemic patients are treated initially with conventional oxygen therapy, and clinicians often transition them to HFNC before progressing to invasive ventilation. Although clinicians might not explicitly use the PaO2:FiO2 ratio to guide that transition, it often occurs at ratios that are lower than this study's threshold of 200. However, this study suggests that earlier use of HFNC might be a better strategy.