Cardiovascular disease and severe hypoxemia associated with higher rates of non-invasive respiratory support failure in COVID-19

Wang, J. G.; Liu, B.; Percha, B.; Pan, S.; Goel, N.; Mathews, K.; Gao, C.; Tandon, P.; Tomlinson, M.; Yoo, E.; Howell, D.; Eisenberg, E.; Naymagon, L.; Tremblay, D.; Chokshi, K.; Dua, S.; Dunn, A.; Powell, C.; Bose, S.

Rationale Acute hypoxemic respiratory failure (AHRF) is the major complication of coronavirus disease 2019 (COVID-19), yet optimal respiratory support strategies are uncertain. Objectives To describe outcomes with high-flow oxygen delivered through nasal cannula (HFNC) and non-invasive positive pressure ventilation (NIPPV) in COVID-19 AHRF and identify individual factors associated with failure. Methods We performed a retrospective cohort study of hospitalized adults with COVID-19 treated with HFNC and/or NIPPV to describe rates of success (live discharge without endotracheal intubation (ETI)), and identify characteristics associated with failure (ETI and/or in-hospital mortality) using Fine-Gray sub-distribution hazard models. Results A total of 331 and 747 patients received HFNC and NIPPV as the highest level of non-invasive respiratory support, respectively; 154 (46.5%) in the HFNC cohort and 167 (22.4%) in the NIPPV cohort were successfully discharged without requiring ETI. In adjusted models, significantly increased risk of HFNC and NIPPV failure was seen among patients with cardiovascular disease (subdistribution hazard ratio (sHR) 1.82; 95% confidence interval (CI), 1.17-2.83 and sHR 1.40; 95% CI 1.06-1.84), respectively, and among those with lower oxygen saturation to fraction of inspired oxygen (SpO2/FiO2) ratio at HFNC and NIPPV initiation (sHR, 0.32; 95% CI 0.19-0.54, and sHR 0.34; 95% CI 0.21-0.55, respectively). Conclusions A significant proportion of patients receiving non-invasive respiratory modalities for COVID-19 AHRF achieved successful discharge without requiring ETI, with lower success rates among those with cardiovascular disease or more severe hypoxia. The role of non-invasive respiratory modalities in COVID-19 related AHRF requires further consideration.