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Meta-Analysis
. 2022 Feb 15;205(4):431-439.
doi: 10.1164/rccm.202109-2163OC.

High-Flow Nasal Oxygen for Severe Hypoxemia: Oxygenation Response and Outcome in Patients with COVID-19

V Marco Ranieri  1   2 , Tommaso Tonetti  1   2 , Paolo Navalesi  3   4 , Stefano Nava  5   6 , Massimo Antonelli  7   8 , Antonio Pesenti  9   10 , Giacomo Grasselli  9   10 , Domenico Luca Grieco  7   8 , Luca Salvatore Menga  8 , Lara Pisani  5   6 , Annalisa Boscolo  4 , Nicolò Sella  3   4 , Laura Pasin  4 , Chiara Mega  1   2 , Giacinto Pizzilli  2 , Alessio Dell'Olio  1 , Roberto Dongilli  11 , Paola Rucci  12 , Arthur S Slutsky  13
Affiliations
Meta-Analysis

High-Flow Nasal Oxygen for Severe Hypoxemia: Oxygenation Response and Outcome in Patients with COVID-19

V Marco Ranieri et al. Am J Respir Crit Care Med. .

Abstract

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 PaO2/FiO2 of ⩽300 while treated with ⩾40 L/min HFNO, or noninvasive ventilation (NIV) with positive end-expiratory pressure of ⩾5 cm H2O (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 PaO2/FiO2 ⩽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 PaO2/FiO2 ⩽300 may identify patients at earlier stages of disease but with lower mortality.

Keywords: ARDS; COVID-19; HFNO; mechanical ventilation; noninvasive ventilation.

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Figures

Figure 1.
Figure 1.
Flow chart of the study. ARF = acute respiratory failure; COVID-19 = coronavirus disease; DNI/DNR = “do not intubate/do not resuscitate” order; HFNO = high-flow nasal oxygen; IMV = invasive mechanical ventilation; NIV = noninvasive ventilation.
Figure 2.
Figure 2.
Values of PaO2/FiO2 ratio before and after intubation in patients treated with HFNO (top) and with NIV (bottom). Horizontal solid lines indicate median values of PaO2/FiO2. Horizontal dotted line indicates the cutoff value of PaO2/FiO2 (⩽300) below which patients are classified as having acute respiratory distress syndrome. Definition of abbreviations. HFNO = high-flow nasal oxygen; NIV = noninvasive ventilation. **P = 0.0013 and ****P < 0.0001.
Figure 3.
Figure 3.
Percentage distribution in the different severity classes before and after institution of IMV for patients on HFNO (top) and NIV (bottom). See text for more details. HFNO = high-flow nasal oxygen; IMV = invasive mechanical ventilation; NIV = noninvasive ventilation; P/F = PaO2/FIO2 ratio.
Figure 4.
Figure 4.
Mortality at Day 28 in the HFNO (left) and NIV (right) groups. Mortality in patients treated with HFNO who were not intubated was 4.2% (3/72), whereas in patients transitioned from HFNO to IMV, mortality was 28.6% (32/112) (P < 0.001). Mortality in patients treated with NIV but not intubated was 1.6% (1/62), whereas in patients who transitioned from NIV to IMV, mortality was 44.9% (31/69) (P < 0.001). Overall mortality in patients initially treated with HFNO and NIV was 19.0% (35/184) and 24.4% (32/131), respectively (P = 0.2479). HFNO = high-flow nasal oxygen; IMV = invasive mechanical ventilation; NIV = noninvasive ventilation.
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References

    1. Thompson BT, Chambers RC, Liu KD. Acute respiratory distress syndrome. N Engl J Med . 2017;377:562–572. - PubMed
    1. Rubenfeld GD. Epidemiology of acute lung injury. Crit Care Med . 2003;31:S276–S284. - PubMed
    1. Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. Acute respiratory distress in adults. Lancet . 1967;2:319–323. - PubMed
    1. Villar J, Blanco J, Kacmarek RM. Acute respiratory distress syndrome definition: do we need a change? Curr Opin Crit Care . 2011;17:13–17. - PubMed
    1. Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, et al. ARDS Definition Task Force Acute respiratory distress syndrome: the Berlin definition. JAMA . 2012;307:2526–2533. - PubMed

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