Higher mortality and intubation rate in COVID-19 patients treated with noninvasive ventilation compared with high-flow oxygen or CPAP

Sergi Marti, Anne-Elie Carsin, Júlia Sampol, Mercedes Pallero, Irene Aldas, Toni Marin, Manel Lujan, Cristina Lalmolda, Gladis Sabater, Marc Bonnin-Vilaplana, Patricia Peñacoba, Juana Martinez-Llorens, Julia Tárrega, Óscar Bernadich, Ana Córdoba-Izquierdo, Lourdes Lozano, Susana Mendez, Eduardo Vélez-Segovia, Elena Prina, Saioa Eizaguirre, Ana Balañá-Corberó, Jaume Ferrer, Judith Garcia-Aymerich, Sergi Marti, Anne-Elie Carsin, Júlia Sampol, Mercedes Pallero, Irene Aldas, Toni Marin, Manel Lujan, Cristina Lalmolda, Gladis Sabater, Marc Bonnin-Vilaplana, Patricia Peñacoba, Juana Martinez-Llorens, Julia Tárrega, Óscar Bernadich, Ana Córdoba-Izquierdo, Lourdes Lozano, Susana Mendez, Eduardo Vélez-Segovia, Elena Prina, Saioa Eizaguirre, Ana Balañá-Corberó, Jaume Ferrer, Judith Garcia-Aymerich

Abstract

The effectiveness of noninvasive respiratory support in severe COVID-19 patients is still controversial. We aimed to compare the outcome of patients with COVID-19 pneumonia and hypoxemic respiratory failure treated with high-flow oxygen administered via nasal cannula (HFNC), continuous positive airway pressure (CPAP) or noninvasive ventilation (NIV), initiated outside the intensive care unit (ICU) in 10 university hospitals in Catalonia, Spain. We recruited 367 consecutive patients aged ≥ 18 years who were treated with HFNC (155, 42.2%), CPAP (133, 36.2%) or NIV (79, 21.5%). The main outcome was intubation or death at 28 days after respiratory support initiation. After adjusting for relevant covariates and taking patients treated with HFNC as reference, treatment with NIV showed a higher risk of intubation or death (hazard ratio 2.01; 95% confidence interval 1.32-3.08), while treatment with CPAP did not show differences (0.97; 0.63-1.50). In the context of the pandemic and outside the intensive care unit setting, noninvasive ventilation for the treatment of moderate to severe hypoxemic acute respiratory failure secondary to COVID-19 resulted in higher mortality or intubation rate at 28 days than high-flow oxygen or CPAP. This finding may help physicians to choose the best noninvasive respiratory support treatment in these patients.Clinicaltrials.gov identifier: NCT04668196.

Conflict of interest statement

The authors declare no competing interests.

© 2022. The Author(s).

Figures

Figure 1
Figure 1
Flowchart. ARF acute respiratory failure, HFNC high-flow nasal cannula, ICU intensive care unit, NIRS non-invasive respiratory support, NIV non-invasive ventilation. *HFNC, n = 2; CPAP, n = 6; NIV, n = 3. In addition, 26 patients who presented early intolerance were treated subsequently with other NIRS treatment, and were included as study patients in this second treatment: 8 patients with intolerance to HFNC (2 patients treated subsequently with CPAP, and 6 with NIV), 11 patients with intolerance to CPAP (5 treated later with HFNC, and 6 with NIV), and 7 patients with intolerance to NIV (5 treated after with HFNC, and 2 with CPAP).
Figure 2
Figure 2
The 28-days Kaplan Meier curves from: (a) day starting NIRS to death or intubation; (b) day starting NIRS to intubation; and (c) day starting NIRS to death. NIRS non-invasive respiratory support.

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