Michael A Garcia1, Shelsey W Johnson2, Emily K Sisson3, Christopher R Sheldrick3, Vishakha K Kumar4, Karen Boman4, Scott Bolesta5, Vikas Bansal6, Marija Bogojevic7, J P Domecq8, Amos Lal7, Smith Heavner9, Sreekanth R Cheruku10, Donna Lee11, Harry L Anderson12, Joshua L Denson13, Ognjen Gajic7, Rahul Kashyap6, Allan J Walkey2,14. 1. The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical Care, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts. Michael.Garcia@bmc.org. 2. The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical Care, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts. 3. Boston University School of Public Health, Boston, Massachusetts. 4. Society of Critical Care Medicine, Mount Prospect, Illinois. 5. Department of Pharmacy Practice, Nesbitt School of Pharmacy, Wilkes University, Wilkes-Barre, Pennsylvania. 6. Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota. 7. Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota. 8. Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota. 9. Department of Emergency Medicine, Prisma Health, Greenville, South Carolina. 10. Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesia and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas. 11. Center for Advanced Analytics, Best Practices, Baptist Health South Florida, Miami, Florida. 12. Department of Surgery, St. Joseph Mercy Ann Arbor Hospital, Ann Arbor, Michigan. 13. Section of Pulmonary, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, Louisiana. 14. Evans Center of Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts.
Abstract
BACKGROUND: The use of high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) for hypoxemic respiratory failure secondary to COVID-19 are recommended by critical-care guidelines; however, apprehension about viral particle aerosolization and patient self-inflicted lung injury may have limited use. We aimed to describe hospital variation in the use and clinical outcomes of HFNC and NIV for the management of COVID-19. METHODS: This was a retrospective observational study of adults hospitalized with COVID-19 who received supplemental oxygen between February 15, 2020, and April 12, 2021, across 102 international and United States hospitals by using the COVID-19 Registry. Associations of HFNC and NIV use with clinical outcomes were evaluated by using multivariable adjusted hierarchical random-effects logistic regression models. Hospital variation was characterized by using intraclass correlation and the median odds ratio. RESULTS: Among 13,454 adults with COVID-19 who received supplemental oxygen, 8,143 (60%) received nasal cannula/face mask only, 2,859 (21%) received HFNC, 878 (7%) received NIV, 1,574 (12%) received both HFNC and NIV, with 3,640 subjects (27%) progressing to invasive ventilation. The hospital of admission contributed to 24% of the risk-adjusted variation in HFNC and 30% of the risk-adjusted variation in NIV. The median odds ratio for hospital variation of HFNC was 2.6 (95% CI 1.4-4.9) and of NIV was 3.1 (95% CI 1.2-8.1). Among 5,311 subjects who received HFNC and/or NIV, 2,772 (52%) did not receive invasive ventilation and survived to hospital discharge. Hospital-level use of HFNC or NIV were not associated with the rates of invasive ventilation or mortality. CONCLUSIONS: Hospital variation in the use of HFNC and NIV for acute respiratory failure secondary to COVID-19 was great but was not associated with intubation or mortality. The wide variation and relatively low use of HFNC/NIV observed within our study signaled that implementation of increased HFNC/NIV use in patients with COVID-19 will require changes to current care delivery practices. (ClinicalTrials.gov registration NCT04323787.).
BACKGROUND: The use of high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) for hypoxemic respiratory failure secondary to COVID-19 are recommended by critical-care guidelines; however, apprehension about viral particle aerosolization and patient self-inflicted lung injury may have limited use. We aimed to describe hospital variation in the use and clinical outcomes of HFNC and NIV for the management of COVID-19. METHODS: This was a retrospective observational study of adults hospitalized with COVID-19 who received supplemental oxygen between February 15, 2020, and April 12, 2021, across 102 international and United States hospitals by using the COVID-19 Registry. Associations of HFNC and NIV use with clinical outcomes were evaluated by using multivariable adjusted hierarchical random-effects logistic regression models. Hospital variation was characterized by using intraclass correlation and the median odds ratio. RESULTS: Among 13,454 adults with COVID-19 who received supplemental oxygen, 8,143 (60%) received nasal cannula/face mask only, 2,859 (21%) received HFNC, 878 (7%) received NIV, 1,574 (12%) received both HFNC and NIV, with 3,640 subjects (27%) progressing to invasive ventilation. The hospital of admission contributed to 24% of the risk-adjusted variation in HFNC and 30% of the risk-adjusted variation in NIV. The median odds ratio for hospital variation of HFNC was 2.6 (95% CI 1.4-4.9) and of NIV was 3.1 (95% CI 1.2-8.1). Among 5,311 subjects who received HFNC and/or NIV, 2,772 (52%) did not receive invasive ventilation and survived to hospital discharge. Hospital-level use of HFNC or NIV were not associated with the rates of invasive ventilation or mortality. CONCLUSIONS: Hospital variation in the use of HFNC and NIV for acute respiratory failure secondary to COVID-19 was great but was not associated with intubation or mortality. The wide variation and relatively low use of HFNC/NIV observed within our study signaled that implementation of increased HFNC/NIV use in patients with COVID-19 will require changes to current care delivery practices. (ClinicalTrials.gov registration NCT04323787.).
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