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. 2023 Jul 14;13(1):64.
doi: 10.1186/s13613-023-01161-6.

Broadening the Berlin definition of ARDS to patients receiving high-flow nasal oxygen: an observational study in patients with acute hypoxemic respiratory failure due to COVID-19

Fleur-Stefanie L I M van der Ven #  1   2 , Christel M A Valk #  3 , Siebe Blok #  3 , Michelle G Brouwer  3 , Dai Ming Go  3 , Amanda Lokhorst  3 , Pien Swart  3 , David M P van Meenen  3   4 , Frederique Paulus  3   5 , Marcus J Schultz  3   6   7   8 ; PRoAcT–COVID study investigators
Collaborators, Affiliations

Broadening the Berlin definition of ARDS to patients receiving high-flow nasal oxygen: an observational study in patients with acute hypoxemic respiratory failure due to COVID-19

Fleur-Stefanie L I M van der Ven et al. Ann Intensive Care. .

Abstract

Background: High-flow nasal oxygen (HFNO) is increasingly used in patients with acute hypoxemic respiratory failure. It is uncertain whether a broadened Berlin definition of acute respiratory distress syndrome (ARDS), in which ARDS can be diagnosed in patients who are not receiving ventilation, results in similar groups of patients receiving HFNO as in patients receiving ventilation.

Methods: We applied a broadened definition of ARDS in a multicenter, observational study in adult critically ill patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19), wherein the requirement for a minimal level of 5 cm H2O PEEP with ventilation is replaced by a minimal level of airflow rate with HFNO, and compared baseline characteristics and outcomes between patients receiving HFNO and patients receiving ventilation. The primary endpoint was ICU mortality. We also compared outcomes in risk for death groups using the PaO2/FiO2 cutoffs as used successfully in the original definition of ARDS. Secondary endpoints were hospital mortality; mortality on days 28 and 90; need for ventilation within 7 days in patients that started with HFNO; the number of days free from HFNO or ventilation; and ICU and hospital length of stay.

Results: Of 728 included patients, 229 patients started with HFNO and 499 patients with ventilation. All patients fulfilled the broadened Berlin definition of ARDS. Patients receiving HFNO had lower disease severity scores and lower PaO2/FiO2 than patients receiving ventilation. ICU mortality was lower in receiving HFNO (22.7 vs 35.6%; p = 0.001). Using PaO2/FiO2 cutoffs for mild, moderate and severe arterial hypoxemia created groups with an ICU mortality of 16.7%, 22.0%, and 23.5% (p = 0.906) versus 19.1%, 37.9% and 41.4% (p = 0.002), in patients receiving HFNO versus patients receiving ventilation, respectively.

Conclusions: Using a broadened definition of ARDS may facilitate an earlier diagnosis of ARDS in patients receiving HFNO; however, ARDS patients receiving HFNO and ARDS patients receiving ventilation have distinct baseline characteristics and mortality rates.

Trial registration: The study is registered at ClinicalTrials.gov (identifier NCT04719182).

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Conflict of interest statement

All authors will complete and submit the ICMJE Form for Disclosure of Potential Competing interest.

Figures

Fig. 1
Fig. 1
CONSORT flowchart of patients included in this analysis. ARDS acute respiratory distress syndrome, FiO2 fraction of inspired oxygen, HFNO high-flow nasal oxygen, ICU intensive care unit, IRB institutional review board, PaO2 partial pressure of oxygen
Fig. 2
Fig. 2
A 28-day survival and B cumulative incidence of liberation of respiratory support in patients receiving HFNO compared to patients receiving ventilation. For survival the adjusted hazard ratio is shown. A shows survival in the first 28 days, and B shows survival until the day of extubation. The cumulative incidence of liberation from respiratory support is shown as unadjusted hazard ratio with center as random effect. CI confidence interval, HFNO high-flow nasal oxygen, HR hazard ratio
Fig. 3
Fig. 3
Outcome in patients receiving ventilation or HFNO, in risk of death groups based on the PaO2/FiO2 cutoffs as in the Berlin definition of ARDS, and in patients receiving HFNO, in risk of death groups based on the tertile PaO2/FiO2 cutoffs. ICU mortality is shown in (A). PaO2/FiO2 cutoffs as in the Berlin definition were 200–300 (mild ARDS), 100–200 (moderate ARDS) and < 100 mmHg (severe ARDS). PaO2/FiO2 cutoffs based on tertiles were 110–300 (mild hypoxemia), 80–110 (moderate hypoxemia) and < 80 mmHg (severe hypoxemia). B shows ICU survival for patients receiving ventilation according to the risk of death groups based on the PaO2/FiO2 cutoffs as in the Berlin definition of ARDS. C shows ICU survival for patients receiving HFNO according to the risk of death groups based on the PaO2/FiO2 cutoffs as in the Berlin definition of ARDS. D shows ICU survival for patients receiving HFNO using PaO2/FiO2 cutoffs based on tertiles. Unadjusted hazard ratios with center as random effect are shown. CI confidence interval, FiO2 fraction of inspired oxygen, HFNO high-flow nasal oxygen, HR hazard ratio, PaO2 partial pressure of oxygen
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