Outcomes with High Flow Nasal Therapy vs Invasive Mechanical Ventilation in COVID-19 Patients with Hypoxemic Respiratory Failure

Abstract

Rationale: Coronavirus disease 2019 (COVID-19) has provoked an unprecedented global pandemic. Invasive mechanical ventilation (IMV) rates in COVID-19 have been reported to be from 2.3% to 33%. The wide range in reported intubation rates is attributed in part to diverging institutional practices for the care of patients presenting with hypoxemic respiratory failure. The role of high flow nasal therapy (HFNT) in the treatment of COVID-19 has been controversial and underreported. Objectives: To report a retrospective analysis comparing the outcomes of patients treated with HFNT and IMV for hypoxemic respiratory failure secondary to COVID-19. Methods: This was an analysis of consecutive patients admitted to Temple University Hospital between March 10, 2020, and May 17, 2020, for moderate to severe hypoxemic respiratory failure from COVID-19 pneumonia. Patients were divided into three groups: IMV group-not placed on HFNT prior to intubation. HFNT group-received only HFNT. HFNT to intubation group-received HFNT prior to intubation. Comparisons were made between demographics, baseline laboratory values, and outcomes. Results: 1396 patients admitted to Temple University Hospital between March 10, 2020, and May 17, 2020 with suspected COVID-19 infection were retrospectively screened for this study. 837 patients tested positive for COVID-19 by nasopharyngeal RT-PCR or deemed positive based on clinical features. There were no statistically significant differences in terms of demographics between all three groups. However, the intubation and HFNT to intubation groups had a higher incidence of malignancy compared to the HFNT only group. There was a higher incidence of smoking in the intubation group (59.2%) and HFNT to intubation group (53.7%) compared to HFNT only group (29.2%). Laboratory data were similar between all three groups besides admission BUN/creatinine. In terms of therapies, high-dose steroids were administered more frequently to patients in the HFNT (84.3%) and HFNT to intubation (90.2%) groups compared to the intubated group (56.5%). Overall, 49 (28.1%) were intubated, 84 (48.2%) were treated with HFNT only, and 41 (23.5%) progressed from HFNT to intubation. The mortality was 36.7% in the intubation group, 6% in the HFNT only group, and 43.9% in the HFNT to intubation group. Overall mortality was 25.7%. Conclusion: Our institutional decision to utilize HFNT as the primary treatment for moderate to severe hypoxemic respiratory failure led to a low intubation rate thus reducing overall morbidity and mortality. In the appropriate clinical context HFNT should be the considered the oxygen modality of choice in moderate to severe hypoxemic respiratory failure secondary to COVID-19 pneumonia.