Skip to main content
 

Main menu

  • Home
  • Content
    • Current Issue
    • Editor's Commentary
    • Coming Next Month
    • Archives
    • Most-Read Papers of 2021
  • Authors
    • Author Guidelines
    • Submit a Manuscript
  • Reviewers
    • Reviewer Information
    • Create Reviewer Account
    • Reviewer Guidelines: Original Research
    • Reviewer Guidelines: Reviews
    • Appreciation of Reviewers
  • CRCE
    • Through the Journal
    • JournalCasts
    • AARC University
    • PowerPoint Template
  • Open Forum
    • 2022 Call for Abstracts
    • 2021 Abstracts
    • Previous Open Forums
  • Podcast
    • English
    • Español
    • Portugûes
    • 国语
  • Videos
    • Video Abstracts
    • Author Interviews
    • Highlighted Articles
    • The Journal

User menu

  • Subscribe
  • My alerts
  • Log in

Search

  • Advanced search
American Association for Respiratory Care
  • Subscribe
  • My alerts
  • Log in
American Association for Respiratory Care

Advanced Search

  • Home
  • Content
    • Current Issue
    • Editor's Commentary
    • Coming Next Month
    • Archives
    • Most-Read Papers of 2021
  • Authors
    • Author Guidelines
    • Submit a Manuscript
  • Reviewers
    • Reviewer Information
    • Create Reviewer Account
    • Reviewer Guidelines: Original Research
    • Reviewer Guidelines: Reviews
    • Appreciation of Reviewers
  • CRCE
    • Through the Journal
    • JournalCasts
    • AARC University
    • PowerPoint Template
  • Open Forum
    • 2022 Call for Abstracts
    • 2021 Abstracts
    • Previous Open Forums
  • Podcast
    • English
    • Español
    • Portugûes
    • 国语
  • Videos
    • Video Abstracts
    • Author Interviews
    • Highlighted Articles
    • The Journal
  • Twitter
  • Facebook
  • YouTube
EditorialEditorials

Predicting Success of High-Flow Nasal Cannula in COVID-19

Robert J Varipapa and Rajiv Sonti
Respiratory Care June 2021, 66 (6) 1044-1045; DOI: https://doi.org/10.4187/respcare.09212
Robert J Varipapa Jr
Division of Pulmonary, Critical Care and Sleep MedicineGeorgetown University Medical CenterWashington, DC
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: [email protected]
Rajiv Sonti
Division of Pulmonary, Critical Care and Sleep MedicineGeorgetown University Medical CenterWashington, DC
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • References
  • Info & Metrics
  • PDF
Loading

High-flow nasal cannula (HFNC) therapy has dramatically changed the management of acute hypoxemic respiratory failure. The ongoing COVID pandemic has only increased its use, and it is a key modality in the management of hypoxemic patients with and without COVID. Predicting which patients may fail HFNC remains a challenge, as does identifying when to transition a failing patient to mechanical ventilation.

In this edition of Respiratory Care, Chandel et al1 retrospectively describe 272 subjects with COVID-19 managed with HFNC. The previously validated respiratory to oxygenation (ROX) index was used to stratify subjects at risk for HFNC failure who would thus require endotracheal intubation.2 This index is simply a ratio of oxygenation (Embedded Image ) to breathing frequency, with a lower number indicative of increased respiratory compromise. A cut-off value of 4.88 was previously reported to differentiate patients with pneumonia at increased risk for intubation.3 In this cohort, a ROX index > 3 was 85% specific for subjects who were able to be weaned from HFNC. As expected, those who “failed” HFNC were significantly older (60 vs 54 y, P < .01), sicker (SOFA score 4 vs 2, P < .01), and possibly more inflamed (neutrophil to lymphocyte ratio 8.1 vs 6.1, P < .01).

Strengths of this study include a large sample size, nearly matching the landmark FLORALI trial.4 The failure group alone contained 108 subjects and allowed for analysis between those who failed HFNC before and after 48 h from initiation of HFNC. Additionally, multivariate analysis was performed, and mortality data were collected and analyzed. Unlike prior ROX studies and many prior ARDS studies, this study looked at a single disease process, namely COVID-19.

Patients were recruited from nearly the beginning of the COVID-19 epidemic in March 2020 through June 2020. While a “COVID-19 management protocol” is described, it is unclear whether this protocol was uniform throughout the study period. Early in the pandemic, many institutions intubated patients with COVID-19 who presented with less severe hypoxemia due to concerns regarding infection control as well as reports of rapid respiratory collapse. A temporal change in practice may have affected which patients were intubated and when.

The use of therapies such as steroids, remdesivir, and inhaled nitric oxide may have changed over the course of the epidemic, especially as new data were published. For instance, the results of the RECOVERY trial5 were not made public until June 2020 and likely led to increased corticosteroid use. The increased rates of steroid use, remdesivir, and self-proning in the late failure group suggest that these treatments were used as salvage rather than upfront therapies. More uniform use of steroids and other emerging evidence-based therapies may have affected which patients failed HFNC.

This report suggests that “late,” beyond 48 h, HFNC failure is not associated with excess mortality and perhaps delaying intubation is not harmful in this population. A study randomized to early vs late intubation in patients treated with HFNC would be difficult to design and possibly unethical. This is why there are so few studies and no clinical studies on the indications for intubation. As there are no consensus guidelines as to when a patient should be intubated, this decision remains largely clinical and will vary from institution to institution and even within providers at a single institution. The absolute difference in mortality of 13.9% (P = .18) raises the question of whether there exists a subgroup of patients who benefit from early intubation.

One has to wonder why a patient fails late during a hospital stay, and perhaps it is less related to self-inflicted lung injury and has more to do with the disease process in that patient and lack of response to the treatments that are being administered. The data presented do not show a difference in complications such as pneumothorax or ventilator-associated pneumonia, though it may be underpowered to do so.

This study again shows the value of the ROX index in predicting failure of HFNC. This information can inform the bedside clinician as to which patients may deteriorate. The ROX index could be used in triage, especially during a pandemic or other situations where ICU services may be overwhelmed. The fact that 67.7% of subjects in this report were managed in a non-ICU setting supports this notion. Additionally, this study suggests that HFNC may delay intubation without leading to increased mortality.

Footnotes

  • Correspondence: Robert J Varipapa Jr MD. E-mail: robert.j.varipapa{at}gunet.georgetown.edu
  • See the Original Study on Page 909

  • The authors have disclosed no conflicts of interest.

  • Copyright © 2021 by Daedalus Enterprises

References

  1. 1.↵
    1. Chandel A,
    2. Patolia S,
    3. Brown AW,
    4. Collins C,
    5. Sahjawani D,
    6. Khangoora V,
    7. et al
    . High-flow nasal cannula therapy in COVID-19: using the ROX index to predict success. Respir Care 2021;66(6):909-919.
    OpenUrlAbstract/FREE Full Text
  2. 2.↵
    1. Roca O,
    2. Caralt B,
    3. Messika J,
    4. Samper M,
    5. Sztrymf B,
    6. Hernández G,
    7. et al
    . An index combining respiratory rate and oxygenation to predict outcome of nasal high-flow therapy. Am J Respir Crit Care Med 2019;199(11):1368-1376.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Roca O,
    2. Messika J,
    3. Caralt B,
    4. García-de-Acilu M,
    5. Sztrymf B,
    6. Ricard J-D,
    7. et al
    . Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: The utility of the ROX index. J Crit Care 2016;35:200-205.
    OpenUrlPubMed
  4. 4.↵
    1. Frat JP,
    2. Thille AW,
    3. Mercat A,
    4. Girault C,
    5. Ragot S,
    6. Perbet S,
    7. et al
    . High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015;372(23):2185-2196.
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. RECOVERY Trial
    . Low-cost dexamethasone reduces death by up to one third in hospitalised patients with severe respiratory complications of COVID-19. Avaialble at: https://www.recoverytrial.net/news/low-cost-dexamethasone-reduces-death-by-up-to-one-third-in-hospitalised-patients-with-severe-respiratory-complications-of-covid-19. Accessed May 4, 2021.
PreviousNext
Back to top

In this issue

Respiratory Care: 66 (6)
Respiratory Care
Vol. 66, Issue 6
1 Jun 2021
  • Table of Contents
  • Table of Contents (PDF)
  • Cover (PDF)
  • Index by author

 

Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on American Association for Respiratory Care.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Predicting Success of High-Flow Nasal Cannula in COVID-19
(Your Name) has sent you a message from American Association for Respiratory Care
(Your Name) thought you would like to see the American Association for Respiratory Care web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Predicting Success of High-Flow Nasal Cannula in COVID-19
Robert J Varipapa, Rajiv Sonti
Respiratory Care Jun 2021, 66 (6) 1044-1045; DOI: 10.4187/respcare.09212

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Predicting Success of High-Flow Nasal Cannula in COVID-19
Robert J Varipapa, Rajiv Sonti
Respiratory Care Jun 2021, 66 (6) 1044-1045; DOI: 10.4187/respcare.09212
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Footnotes
    • References
  • Info & Metrics
  • References
  • PDF

Related Articles

Cited By...

Info For

  • Subscribers
  • Institutions
  • Advertisers

About Us

  • About the Journal
  • Editorial Board
  • Reprints/Permissions

AARC

  • Membership
  • Meetings
  • Clinical Practice Guidelines

More

  • Contact Us
  • RSS
American Association for Respiratory Care

Print ISSN: 0020-1324        Online ISSN: 1943-3654

© Daedalus Enterprises, Inc.

Powered by HighWire