Cardiovascular Disease and Severe Hypoxemia Are Associated With Higher Rates of Noninvasive Respiratory Support Failure in Coronavirus Disease 2019 Pneumonia

  1. Jing Gennie Wang
  2. Bian Liu
  3. Bethany Percha
  4. Stephanie Pan
  5. Neha Goel
  6. Kusum S. Mathews
  7. Cynthia Gao
  8. Pranai Tandon
  9. Max Tomlinson
  10. Edwin Yoo
  11. Daniel Howell
  12. Elliot Eisenberg
  13. Leonard Naymagon
  14. Douglas Tremblay
  15. Krishna Chokshi
  16. Sakshi Dua
  17. Andrew S. Dunn
  18. Charles A. Powell
  19. Sonali Bose

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Abstract

Acute hypoxemic respiratory failure is the major complication of coronavirus disease 2019, yet optimal respiratory support strategies are uncertain. We aimed to describe outcomes with high-flow oxygen delivered through nasal cannula and noninvasive positive pressure ventilation in coronavirus disease 2019 acute hypoxemic respiratory failure and identify individual factors associated with noninvasive respiratory support failure.

Design:

Retrospective cohort study to describe rates of high-flow oxygen delivered through nasal cannula and/or noninvasive positive pressure ventilation success (live discharge without endotracheal intubation). Fine-Gray subdistribution hazard models were used to identify patient characteristics associated with high-flow oxygen delivered through nasal cannula and/or noninvasive positive pressure ventilation failure (endotracheal intubation and/or in-hospital mortality).

Setting:

One large academic health system, including five hospitals (one quaternary referral center, a tertiary hospital, and three community hospitals), in New York City.

Patients:

All hospitalized adults 18–100 years old with coronavirus disease 2019 admitted between March 1, 2020, and April 28, 2020.

Interventions:

None.

Measurements and Main Results:

A total of 331 and 747 patients received high-flow oxygen delivered through nasal cannula and noninvasive positive pressure ventilation as the highest level of noninvasive respiratory support, respectively; 154 (46.5%) in the high-flow oxygen delivered through nasal cannula cohort and 167 (22.4%) in the noninvasive positive pressure ventilation cohort were successfully discharged without requiring endotracheal intubation. In adjusted models, significantly increased risk of high-flow oxygen delivered through nasal cannula and noninvasive positive pressure ventilation failure was seen among patients with cardiovascular disease (subdistribution hazard ratio, 1.82; 95% CI, 1.17–2.83 and subdistribution hazard ratio, 1.40; 95% CI, 1.06–1.84, respectively). Conversely, a higher peripheral blood oxygen saturation to F io 2 ratio at high-flow oxygen delivered through nasal cannula and noninvasive positive pressure ventilation initiation was associated with reduced risk of failure (subdistribution hazard ratio, 0.32; 95% CI, 0.19–0.54, and subdistribution hazard ratio 0.34; 95% CI, 0.21–0.55, respectively).

Conclusions:

A significant proportion of patients receiving noninvasive respiratory modalities for coronavirus disease 2019 acute hypoxemic respiratory failure achieved successful hospital discharge without requiring endotracheal intubation, with lower success rates among those with comorbid cardiovascular disease or more severe hypoxemia. The role of high-flow oxygen delivered through nasal cannula and noninvasive positive pressure ventilation in coronavirus disease 2019–related acute hypoxemic respiratory failure warrants further consideration.

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  1. Version published to 10.1097/cce.0000000000000355
  2. ScreenIT

    SciScore for 10.1101/2020.09.27.20202747: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: The Icahn School of Medicine at Mount Sinai institutional review board approved the study, and the requirement for informed consent was waived due to minimal risk.
    Consent: The Icahn School of Medicine at Mount Sinai institutional review board approved the study, and the requirement for informed consent was waived due to minimal risk.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC), and R (Version 3.5.0) using Rstudio (Version 1.1.453, RStudio, Inc.).
    SAS Institute
    suggested: (Statistical Analysis System, RRID:SCR_008567)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    This study also has several limitations. As an observational study, we cannot draw conclusions on the utility of HFNC and NIPPV compared to low-flow supplemental oxygen. However, our study provides a strong basis for further efforts, including case-control studies and randomized controlled trials to investigate the efficacy of non-invasive respiratory support in reducing risks of ETI and mortality. Additionally, we chose to focus on factors at the time of HFNC or NIPPV initiation associated with treatment outcome and did not address the impact of subsequent changes in clinical characteristics or treatments administered. We were also limited to using SpO2/FiO2 ratios to approximate degree of hypoxemia (43), for which accurate interpretation of severity may be limited as arterial blood gases were unavailable for most patients. Furthermore, we did not account for HFNC flow rates and NIPPV inspiratory/expiratory pressures, which may have influenced outcomes. Finally, we did not assess healthcare worker infectious exposure risk, though prior studies of healthcare workers exposed to SARS-CoV 1 patients on HFNC or NIPPV did not report significantly higher transmission risk (44, 45) and in a COVID-19 simulation study, the exhaled air dispersion during well-fitted HFNC and CPAP use was limited (46).

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  3. Version published to 10.1101/2020.09.27.20202747v1 on medRxiv