Continuous Positive Airway Pressure Might Help Avoid Intubation for Patients with COVID-19

Early in the COVID-19 pandemic, we worried about running out of ventilators to support patients with hypoxemic respiratory failure. In that setting, clinicians sought strategies to avoid intubation, including use of continuous positive airway pressure (CPAP) and high-flow nasal cannula (HFNC). Small studies of these interventions have had mixed results (NEJM JW Gen Med May 15 2021 and JAMA 2021; 325:1731; NEJM JW Gen Med Feb 1 2022 and JAMA 2021; 326:2161).

Investigators from the U.K. randomized more than 1200 patients (mean age, 57) with COVID-19 and acute hypoxemic respiratory failure (oxygen saturation ≤94% while receiving fraction of inspired oxygen of ≥0.40) to conventional oxygen therapy, HFNC, or CPAP. Decisions about intubation were not protocolized and were determined by treating clinicians. The trial was not designed to compare HFNC and CPAP but instead to compare each of these with conventional oxygen therapy. Significantly fewer patients treated with CPAP than with conventional oxygen therapy required intubation (33% vs. 41%), but mortality was similar in both groups. Mortality or intubation with HFNC was similar to that with conventional oxygen therapy. CPAP patients had more adverse events, including claustrophobia, pressure sores, and intolerance of the interface.