Abstract
Background: High-flow nasal cannula (HFNC) may help avoid intubation of hypoxemic patients suffering from COVID-19; however, it may also contribute to delaying intubation, which may increase mortality. Here, we aimed to identify the predictors of HFNC failure among patients with COVID-19. Methods: We performed a multicenter retrospective study in China from January 15 to March 31, 2020. Two centers in Wuhan (resource-limited centers) enrolled 32 patients, and four centers outside Wuhan enrolled 34 cases. HFNC failure was defined as the requirement of escalation therapy (NIV or intubation). The ROX index (the ratio of SpO2/FiO2 to the respiratory rate) was calculated. Results: Among the 66 patients, 29 (44%) cases experienced HFNC failure. The ROX index was much lower in failing patients than in successful ones after 1, 2, 4, 8, 12, and 24 h of HFNC. The ROX index was independently associated with HFNC failure (OR = 0.65; 95% CI: 0.45–0.94) among the variables collected before and 1 h after HFNC. To predict HFNC failure tested by ROX index, the AUC was between 0.73 and 0.79 for the time points of measurement 1–24 h after HFNC initiation. The HFNC failure rate was not different between patients in and outside Wuhan (41% vs. 47%, p = 0.63). However, the time from HFNC initiation to intubation was longer in Wuhan than that outside Wuhan (median 63 vs. 22 h, p = 0.02). Four patients in Wuhan underwent intubation due to cardiac arrest; in contrast, none of the patients outside Wuhan received intubation (13 vs. 0%, p = 0.05). The mortality was higher in Wuhan than that out of Wuhan, but the difference did not reach statistical significance (31 vs. 12%, p = 0.07). Conclusion: The ROX index can be used to predict HFNC failure among COVID-19 patients to avoid delayed intubation, which may occur in the resource-limited area.
Highlights
As of January 17, 2021, more than ninety million cases were confirmed with 2019 novel coronavirus disease (COVID-19) worldwide, with a fatality rate of approximately 2% (WHO Coronavirus Disease Dashboard, 2021)
High-flow nasal cannula (HFNC) may help avoid intubation of hypoxemic patients suffering from COVID-19; it may contribute to delaying intubation, which may increase mortality
The ROX index was independently associated with high-flow nasal cannula (HFNC) failure among the variables collected before and 1 h after HFNC
Summary
As of January 17, 2021, more than ninety million cases were confirmed with 2019 novel coronavirus disease (COVID-19) worldwide, with a fatality rate of approximately 2% (WHO Coronavirus Disease Dashboard, 2021). High-flow nasal cannula (HFNC) has been proven to improve oxygenation and reduce intubation rates for hypoxemic respiratory failure patients of various etiologies (Li et al, 2020a). HFNC provides gas flow higher than the patient’s inspiratory flow demand, which enables the delivery of a constant fraction of inspired oxygen (FiO2) without dilution by room air. It washes out the dead space and provides, to some extent, positive expiratory pressure (Nishimura, 2016). High-flow nasal cannula (HFNC) may help avoid intubation of hypoxemic patients suffering from COVID-19; it may contribute to delaying intubation, which may increase mortality. We aimed to identify the predictors of HFNC failure among patients with COVID-19
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