High-Flow Nasal Cannula Treatment in Patients with COVID-19 Acute Hypoxemic Respiratory Failure

Background: The increasing burden of coronavirus disease 2019 (COVID-19)-related acute hypoxemic respiratory failure (AHRF) is straining intensive care unit (ICU) resources globally. Early use of high-flow nasal cannula (HFNC) decreases the need for endotracheal intubation (EI) in different causes of respiratory failure. While HFNC is used in COVID-19-related AHRF, its efficacy remains to be investigated. We aimed to examine whether the use of high-flow nasal oxygen therapy (HFNO) prevents the need for intubation in COVID-19 with (AHRF). Methods: This is a single-center prospective observational study that was conducted at a tertiary teaching hospital in Saudi Arabia the period from April, 2020 to August, 2020. Adults patients admitted to the ICU with AHRF secondary to COVID-19 pneumonia and managed with HFNC were included. We excluded hemodynamically unstable patients and those who were intubated or managed with non-invasive ventilation. Patients’ data and clinical outcomes were pre-defined. The primary outcome was to determine the rate of EI among patients who were treated with HFNC. Secondary outcomes included predictors of HFNC success/failure, mortality, and hospital length of stay. Results: We consecutively screened 111 hospitalized COVID-19 patients with AHRF,. Out of those, 44 (40%) patients received HFNC with a median duration of three days (IQR, 1–5). The median age was 57 years (interquartile range [IQR], 46–64), and 82% were men. HFNC failure and EI occurred in 29 (66%) patients. Patients who failed HFNC treatment had higher risk of death compared to those who did not (52% vs. 0%; p=0.001). At baseline, the prevalence of hypertension, chronic kidney disease, and asthma was higher in the HFNC failure group. After adjustment for possible confounders, a high Sequential Organ Failure Assessment (SOFA) score and a low ROX index were significantly associated with HFNC failure (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.04–1.93; p=0.025; and HR, 0.61; 95% CI, 0.42–0.88; p=0.008, respectively). Conclusions: In this prospective study, one-third of hypoxemic COVID-19 patients who received HFNC did not require intubation. High SOFA score and low ROX index were associated with HFNC failure.