Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Clinical Trial
. 2022 Sep;67(9):1091-1099.
doi: 10.4187/respcare.09772. Epub 2022 Jun 28.

Predictors of Respiratory Support Use in Emergency Department Patients With COVID-19-Related Respiratory Failure

Neha N Goel  1 , Erin Eschbach  2 , Daniel McConnell  3 , Bryan Beattie  3 , Sean Hickey  3 , John Rozehnal  3 , Evan Leibner  3 , Gary Oldenburg  4 , Kusum S Mathews  5
Affiliations
Clinical Trial

Predictors of Respiratory Support Use in Emergency Department Patients With COVID-19-Related Respiratory Failure

Neha N Goel et al. Respir Care. 2022 Sep.

Abstract

Background: Given the known downstream implications of choice of respiratory support on patient outcomes, all factors influencing these decisions, even those not limited to the patient, warrant close consideration. We examined the effect of emergency department (ED)-specific system factors, such as work load and census, on the use of noninvasive versus invasive respiratory support.

Methods: We conducted a multi-center retrospective cohort study of all adult subjects with severe COVID-19 requiring an ICU admission from 5 EDs within a single urban health care system. Subject demographics, severity of illness, and the type of respiratory support used were obtained. Using continuous measures of ED census, boarding, and active management, we estimated ED work load for each subjects' ED stay. The subjects were categorized by type(s) of respiratory support used: low-flow oxygen, noninvasive respiratory support (eg, noninvasive ventilation [NIV] and/or high-flow nasal cannula [HFNC]), invasive mechanical ventilation, or invasive mechanical ventilation after trial of NIV/HFNC. We used multivariable logistic regression to examine system factors associated with the type of respiratory support used in the ED.

Results: A total of 634 subjects were included. Of these, 431 (70.0%) were managed on low-flow oxygen alone, 108 (17.0%) on NIV/HFNC, 54 (8.5%) on invasive mechanical ventilation directly, and 41 (6.5%) on NIV/HFNC prior to invasive mechanical ventilation in the ED. Higher severity of illness and underlying lung disease increased the odds of requiring invasive mechanical ventilation compared to low-flow oxygen (odds ratio 1.05 [95% CI 1.03-1.07] and odds ratio 3.47 [95% CI 1.37-8.78], respectively). Older age decreased odds of being on invasive mechanical ventilation compared to low-flow oxygen (odds ratio 0.96 [95% CI 0.94-0.99]). As ED work load increased, the odds for subjects to be managed initially with NIV/HFNC prior to invasive mechanical ventilation increased 6-8-fold.

Conclusions: High ED work load was associated with higher odds on HFNC/NIV prior to invasive mechanical ventilation.

Keywords: ED workload; noninvasive ventilation; respiratory support; system factors.

PubMed Disclaimer

Conflict of interest statement

Dr Mathews has received study support from the National Institutes of Health National Heart, Lung, and Blood Institute (Awards: 1K23HL130648-PI: Mathews). The other authors have disclosed no conflicts of interest.

References

    1. Stefan MS, Shieh MS, Pekow PS, Rothberg MB, Steingrub JS, Lagu T, et al. . Epidemiology and outcomes of acute respiratory failure in the United States, 2001 to 2009: a national survey. J Hosp Med 2013;8(2):76-82. - PMC - PubMed
    1. Schnell D, Timsit JF, Darmon M, Vesin A, Goldgran-Toledano D, Dumenil AS, et al. . Noninvasive mechanical ventilation in acute respiratory failure: trends in use and outcomes. Intensive Care Med 2014;40(4):582-591. - PubMed
    1. Demoule A, Girou E, Richard JC, Taille S, Brochard L. Increased use of noninvasive ventilation in French intensive care units. Intensive Care Med 2006;32(11):1747-1755. - PubMed
    1. Ozsancak Ugurlu A, Sidhom SS, Khodabandeh A, Ieong M, Mohr C, Lin DY, et al. . Where is noninvasive ventilation actually delivered for acute respiratory failure? Lung 2015;193(5):779-788. - PubMed
    1. Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al. ; REVA Network. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015;372(23):2185-2196. - PubMed