Ricard Mellado-Artigas1, Bruno L Ferreyro2,3, Federico Angriman3,4, María Hernández-Sanz5, Egoitz Arruti6, Antoni Torres7,8,9, Jesús Villar8,10,11, Laurent Brochard3,11, Carlos Ferrando12,8. 1. Department of Anesthesiology and Critical Care, Institut D'investigació August Pi I Sunyer, Hospital Clínic, Villarroel 170, 08025, Barcelona, Spain. rmartigas@gmail.com. 2. Department of Medicine, Sinai Health System and University Health Network, Toronto, Canada. 3. Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. 4. Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada. 5. Department of Anesthesiology and Critical Care, Hospital de Cruces, Vizcaya, Spain. 6. Ubikare Technology, Vizcaya, Spain. 7. Department of Respirology, Hospital Clínic, Institut D'investigació August Pi i Sunyer, Barcelona, Spain. 8. CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain. 9. CIBERESUCICOVID, Instituto de Salud Carlos III, Madrid, Spain. 10. Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain. 11. Keenan Research Centre for Biomedical Science at the Li Kan Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada. 12. Department of Anesthesiology and Critical Care, Institut D'investigació August Pi I Sunyer, Hospital Clínic, Villarroel 170, 08025, Barcelona, Spain.
Abstract
PURPOSE: Whether the use of high-flow nasal oxygen in adult patients with COVID-19 associated acute respiratory failure improves clinically relevant outcomes remains unclear. We thus sought to assess the effect of high-flow nasal oxygen on ventilator-free days, compared to early initiation of invasive mechanical ventilation, on adult patients with COVID-19. METHODS: We conducted a multicentre cohort study using a prospectively collected database of patients with COVID-19 associated acute respiratory failure admitted to 36 Spanish and Andorran intensive care units (ICUs). Main exposure was the use of high-flow nasal oxygen (conservative group), while early invasive mechanical ventilation (within the first day of ICU admission; early intubation group) served as the comparator. The primary outcome was ventilator-free days at 28 days. ICU length of stay and all-cause in-hospital mortality served as secondary outcomes. We used propensity score matching to adjust for measured confounding. RESULTS: Out of 468 eligible patients, a total of 122 matched patients were included in the present analysis (61 for each group). When compared to early intubation, the use of high-flow nasal oxygen was associated with an increase in ventilator-free days (mean difference: 8.0 days; 95% confidence interval (CI): 4.4 to 11.7 days) and a reduction in ICU length of stay (mean difference: - 8.2 days; 95% CI - 12.7 to - 3.6 days). No difference was observed in all-cause in-hospital mortality between groups (odds ratio: 0.64; 95% CI: 0.25 to 1.64). CONCLUSIONS: The use of high-flow nasal oxygen upon ICU admission in adult patients with COVID-19 related acute hypoxemic respiratory failure may lead to an increase in ventilator-free days and a reduction in ICU length of stay, when compared to early initiation of invasive mechanical ventilation. Future studies should confirm our findings.
PURPOSE: Whether the use of high-flow nasal oxygen in adult patients with COVID-19 associated acute respiratory failure improves clinically relevant outcomes remains unclear. We thus sought to assess the effect of high-flow nasal oxygen on ventilator-free days, compared to early initiation of invasive mechanical ventilation, on adult patients with COVID-19. METHODS: We conducted a multicentre cohort study using a prospectively collected database of patients with COVID-19 associated acute respiratory failure admitted to 36 Spanish and Andorran intensive care units (ICUs). Main exposure was the use of high-flow nasal oxygen (conservative group), while early invasive mechanical ventilation (within the first day of ICU admission; early intubation group) served as the comparator. The primary outcome was ventilator-free days at 28 days. ICU length of stay and all-cause in-hospital mortality served as secondary outcomes. We used propensity score matching to adjust for measured confounding. RESULTS: Out of 468 eligible patients, a total of 122 matched patients were included in the present analysis (61 for each group). When compared to early intubation, the use of high-flow nasal oxygen was associated with an increase in ventilator-free days (mean difference: 8.0 days; 95% confidence interval (CI): 4.4 to 11.7 days) and a reduction in ICU length of stay (mean difference: - 8.2 days; 95% CI - 12.7 to - 3.6 days). No difference was observed in all-cause in-hospital mortality between groups (odds ratio: 0.64; 95% CI: 0.25 to 1.64). CONCLUSIONS: The use of high-flow nasal oxygen upon ICU admission in adult patients with COVID-19 related acute hypoxemic respiratory failure may lead to an increase in ventilator-free days and a reduction in ICU length of stay, when compared to early initiation of invasive mechanical ventilation. Future studies should confirm our findings.
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