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Fisher JM, Subbian V, Essay P, Pungitore S, Bedrick EJ, Mosier JM. Acute Respiratory Failure From Early Pandemic COVID-19: Noninvasive Respiratory Support vs Mechanical Ventilation. CHEST CRITICAL CARE 2024; 2:100030. [PMID: 38645483 PMCID: PMC11027508 DOI: 10.1016/j.chstcc.2023.100030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
BACKGROUND The optimal strategy for initial respiratory support in patients with respiratory failure associated with COVID-19 is unclear, and the initial strategy may affect outcomes. RESEARCH QUESTION Which initial respiratory support strategy is associated with improved outcomes in patients with COVID-19 with acute respiratory failure? STUDY DESIGN AND METHODS All patients with COVID-19 requiring respiratory support and admitted to a large health care network were eligible for inclusion. We compared patients treated initially with noninvasive respiratory support (NIRS; noninvasive positive pressure ventilation by facemask or high-flow nasal oxygen) with patients treated initially with invasive mechanical ventilation (IMV). The primary outcome was time to in-hospital death analyzed using an inverse probability of treatment weighted Cox model adjusted for potential confounders. Secondary outcomes included unweighted and weighted assessments of mortality, lengths of stay (ICU and hospital), and time to intubation. RESULTS Nearly one-half of the 2,354 patients (47%) who met inclusion criteria received IMV first, and 53% received initial NIRS. Overall, in-hospital mortality was 38% (37% for IMV and 39% for NIRS). Initial NIRS was associated with an increased hazard of death compared with initial IMV (hazard ratio, 1.42; 95% CI, 1.03-1.94), but also an increased hazard of leaving the hospital sooner that waned with time (noninvasive support by time interaction: hazard ratio, 0.97; 95% CI, 0.95-0.98). INTERPRETATION Patients with COVID-19 with acute hypoxemic respiratory failure initially treated with NIRS showed an increased hazard of in-hospital death.
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Affiliation(s)
- Julia M Fisher
- Statistics Consulting Laboratory, The University of Arizona College of Medicine, Tucson, AZ; College of Engineering, the BI05 Institute, The University of Arizona College of Medicine, Tucson, AZ
| | - Vignesh Subbian
- Department of Systems and Industrial Engineering, The University of Arizona College of Medicine, Tucson, AZ; Department of Biomedical Engineering, The University of Arizona College of Medicine, Tucson, AZ; College of Engineering, the BI05 Institute, The University of Arizona College of Medicine, Tucson, AZ
| | - Patrick Essay
- Department of Systems and Industrial Engineering, The University of Arizona College of Medicine, Tucson, AZ
| | - Sarah Pungitore
- Program in Applied Mathematics, The University of Arizona College of Medicine, Tucson, AZ
| | - Edward J Bedrick
- Statistics Consulting Laboratory, The University of Arizona College of Medicine, Tucson, AZ; College of Engineering, the BI05 Institute, The University of Arizona College of Medicine, Tucson, AZ
| | - Jarrod M Mosier
- The University of Arizona, the Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ; Division of Pulmonary, Allergy, Critical Care, and Sleep, The University of Arizona College of Medicine, Tucson, AZ; Department of Medicine, The University of Arizona College of Medicine, Tucson, AZ
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de Carvalho VCP, da Silva Guimarães BL, Fujihara MTF, Ceotto VF, Turon R, Lugon JR, Gismondi RAOC. Daily ROX index can predict transitioning to mechanical ventilation within the next 24 h in COVID-19 patients on HFNC. Am J Emerg Med 2023; 73:160-165. [PMID: 37688983 DOI: 10.1016/j.ajem.2023.08.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 09/11/2023] Open
Abstract
INTRODUCTION High flow nasal cannula (HFNC) is used to prevent invasive ventilation in COVID-19-associated hypoxemia. The respiratory rate‑oxygenation (ROX) index has been reported to predict failure of HFNC in patients with COVID-19 pneumonia during the intensive care unit stay when measured in first hours of therapy. However, the clinical course of ICU patients may change substantially in the first days of admission. The objective of this study was to investigate whether ROX index obtained in the first four days of ICU admission could predict the need for invasive respiratory support within the next 24 h of measurements. METHODS A retrospective cross-sectional study was performed using a database that included adult patients with COVID-19 pneumonia treated in the ICU. Patients were followed from ICU admission and ROX index was calculated daily on HFNC. Receiver operating characteristics curves (ROCs) were performed. RESULTS Two hundred forty-nine patients were enrolled, 48% of whom require mechanical ventilation (MV). The area under the ROC of the pooled 4-day values of the ROX index as a predictor of transition from HFNC to MV within 24 h of measurements was 0.86 (95%CI 0.83 to 0.88, P < 0.001) with a cutoff point of 4.06. CONCLUSION In COVID-19 patients in high flow nasal cannula, daily ROX index measurements successfully predicted transition to mechanical ventilation within the next 24 h.
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Affiliation(s)
| | | | | | | | - Ricardo Turon
- Intensive Care Unit, Hospital Niteroi D'Or, Niteroi, Rio de Janeiro, Brazil
| | - Jocemir Ronaldo Lugon
- Department of Medicine, Medical School, Universidade Federal Fluminense, Niteroi, Rio de Janeiro, Brazil
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Erratum: High-Flow Nasal Cannula Failure Odds Is Largely Independent of Duration of Use in COVID-19. Am J Respir Crit Care Med 2023; 208:907. [PMID: 37830794 DOI: 10.1164/rccm.v208erratum2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023] Open
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Myers LC, Kipnis P, Greene JD, Chen A, Creekmur B, Xu S, Sankar V, Roubinian NH, Langer-Gould A, Gould MK, Liu VX. The impact of timing of initiating invasive mechanical ventilation in COVID-19-related respiratory failure. J Crit Care 2023; 77:154322. [PMID: 37163851 PMCID: PMC10165890 DOI: 10.1016/j.jcrc.2023.154322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 03/17/2023] [Accepted: 04/06/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE Optimal timing of initiating invasive mechanical ventilation (IMV) in coronavirus disease 2019 (COVID-19)-related respiratory failure is unclear. We hypothesized that a strategy of IMV as opposed to continuing high flow oxygen or non-invasive mechanical ventilation each day after reaching a high FiO2 threshold would be associated with worse in-hospital mortality. METHODS Using data from Kaiser Permanente Northern/Southern California's 36 medical centers, we identified patients with COVID-19-related acute respiratory failure who reached ≥80% FiO2 on high flow nasal cannula or non-invasive ventilation. Exposure was IMV initiation each day after reaching high FiO2 threshold (T0). We developed propensity scores with overlap weighting for receipt of IMV each day adjusting for confounders. We reported relative risk of inpatient death with 95% Confidence Interval. RESULTS Of 28,035 hospitalizations representing 21,175 patient-days, 5758 patients were included (2793 received and 2965 did not receive IMV). Patients receiving IMV had higher unadjusted mortality (63.6% versus 18.2%, P < 0.0001). On each day after reaching T0 through day >10, the adjusted relative risk was higher for those receiving IMV compared to those not receiving IMV (Relative Risk>1). CONCLUSIONS Initiation of IMV on each day after patients reach high FiO2 threshold was associated with higher inpatient mortality after adjusting for time-varying confounders. Remaining on high flow nasal cannula or non-invasive ventilation does not appear to be harmful compared to IMV. Prospective evaluation is needed.
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Affiliation(s)
- Laura C Myers
- Division of Research and The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, United States of America.
| | - Patricia Kipnis
- Division of Research and The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - John D Greene
- Division of Research and The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Aiyu Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | - Beth Creekmur
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | - Stan Xu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | - Viji Sankar
- Southern California Permanente Medical Group, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | - Nareg H Roubinian
- Division of Research and The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Annette Langer-Gould
- Southern California Permanente Medical Group, Kaiser Permanente Southern California, Pasadena, CA, United States of America; Clinical & Translational Neuroscience, Kaiser Permanente and Southern California Permanente Medical Group, Los Angeles, CA, United States of America
| | - Michael K Gould
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America; Southern California Permanente Medical Group, Kaiser Permanente Southern California, Pasadena, CA, United States of America; Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States of America
| | - Vincent X Liu
- Division of Research and The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, United States of America
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Frat JP, Marchasson L, Arrivé F, Coudroy R. High-flow nasal cannula oxygen therapy in acute hypoxemic respiratory failure and COVID-19-related respiratory failure. JOURNAL OF INTENSIVE MEDICINE 2023; 3:20-26. [PMID: 36756183 PMCID: PMC9534601 DOI: 10.1016/j.jointm.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/19/2022] [Accepted: 07/13/2022] [Indexed: 11/17/2022]
Abstract
Although standard oxygen face masks are first-line therapy for patients with acute hypoxemic respiratory failure, high-flow nasal cannula oxygen therapy has gained major popularity in intensive care units. The physiological effects of high-flow oxygen counterbalance the physiological consequences of acute hypoxemic respiratory failure by lessening the deleterious effects of intense and prolonged inspiratory efforts generated by patients. Its simplicity of application for physicians and nurses and its comfort for patients are other arguments for its use in this setting. Although clinical studies have reported a decreased risk of intubation with high-flow oxygen compared with standard oxygen, its survival benefit is uncertain. A more precise definition of acute hypoxemic respiratory failure, including a classification of severity based on oxygenation levels, is needed to better compare the efficiencies of different non-invasive oxygenation support methods (standard oxygen, high-flow oxygen, and non-invasive ventilation). Additionally, the respective role of each non-invasive oxygenation support method needs to be established through further clinical trials in acute hypoxemic respiratory failure, especially in severe forms.
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Affiliation(s)
- Jean-Pierre Frat
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers 86021, France,Centre d'Investigation Clinique 1402 ALIVE, INSERM, Université de Poitiers, Poitiers 86021, France,Corresponding author: Jean-Pierre Frat, Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers 86021, France
| | - Laura Marchasson
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers 86021, France
| | - François Arrivé
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers 86021, France
| | - Rémi Coudroy
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers 86021, France,Centre d'Investigation Clinique 1402 ALIVE, INSERM, Université de Poitiers, Poitiers 86021, France
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Fisher JM, Subbian V, Essay P, Pungitore S, Bedrick EJ, Mosier JM. Outcomes in Patients with Acute Hypoxemic Respiratory Failure Secondary to COVID-19 Treated with Noninvasive Respiratory Support versus Invasive Mechanical Ventilation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.12.19.22283704. [PMID: 36597544 PMCID: PMC9810223 DOI: 10.1101/2022.12.19.22283704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Purpose The goal of this study was to compare noninvasive respiratory support to invasive mechanical ventilation as the initial respiratory support in COVID-19 patients with acute hypoxemic respiratory failure. Methods All patients admitted to a large healthcare network with acute hypoxemic respiratory failure associated with COVID-19 and requiring respiratory support were eligible for inclusion. We compared patients treated initially with noninvasive respiratory support (noninvasive positive pressure ventilation by facemask or high flow nasal oxygen) with patients treated initially with invasive mechanical ventilation. The primary outcome was time-to-in-hospital death analyzed using an inverse probability of treatment weighted Cox model adjusted for potential confounders. Secondary outcomes included unweighted and weighted assessments of mortality, lengths-of-stay (intensive care unit and hospital) and time-to-intubation. Results Over the study period, 2354 patients met inclusion criteria. Nearly half (47%) received invasive mechanical ventilation first and 53% received initial noninvasive respiratory support. There was an overall 38% in-hospital mortality (37% for invasive mechanical ventilation and 39% for noninvasive respiratory support). Initial noninvasive respiratory support was associated with an increased hazard of death compared to initial invasive mechanical ventilation (HR: 1.61, p < 0.0001, 95% CI: 1.33 - 1.94). However, patients on initial noninvasive respiratory support also experienced an increased hazard of leaving the hospital sooner, but the hazard ratio waned with time (HR: 0.97, p < 0.0001, 95% CI: 0.96 - 0.98). Conclusion These data show that the COVID-19 patients with acute hypoxemic respiratory failure initially treated with noninvasive respiratory support had an increased hazard of in-hospital death.
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Affiliation(s)
- Julia M Fisher
- Statistics Consulting Laboratory, The University of Arizona, Tucson, AZ
- BIO5 Institute, The University of Arizona, Tucson, AZ
| | - Vignesh Subbian
- Department of Systems and Industrial Engineering, College of Engineering, The University of Arizona, Tucson, AZ
- Department of Biomedical Engineering, College of Engineering, The University of Arizona, Tucson, AZ
- BIO5 Institute, The University of Arizona, Tucson, AZ
| | - Patrick Essay
- Department of Systems and Industrial Engineering, College of Engineering, The University of Arizona, Tucson, AZ
| | - Sarah Pungitore
- Program in Applied Mathematics, The University of Arizona, Tucson, AZ
| | - Edward J Bedrick
- Statistics Consulting Laboratory, The University of Arizona, Tucson, AZ
- BIO5 Institute, The University of Arizona, Tucson, AZ
| | - Jarrod M Mosier
- Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of Medicine, The University of Arizona College of Medicine, Tucson, AZ
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McNicholas BA, Ehrmann S, Laffey JG. Awake prone positioning. Intensive Care Med 2022; 48:1793-1795. [PMID: 36151334 PMCID: PMC9510305 DOI: 10.1007/s00134-022-06893-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/27/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Bairbre A McNicholas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland.,School of Medicine, University of Galway, Galway, Ireland
| | - Stephan Ehrmann
- CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSEP F-CRIN Research Network, and Centre d'étude Des Pathologies Respiratoires, INSERM U1100, Université de Tours, Tours, France
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland. .,School of Medicine, University of Galway, Galway, Ireland.
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