Delayed Intubation Associated With In-hospital Mortality in Patients With COVID-19 Respiratory Failure who Fail Heated and Humified High Flow Nasal Canula

Christian Bime; Gordon E. Carr; Jie PU; Sherri Kou; Ying Wang; Michael Simons

BMC Anesthesiol. 2023;23(234)

Abstract and Introduction

Abstract

Background: Advanced respiratory support modalities such as non-invasive positive pressure ventilation (NiPPV) and heated and humidified high flow nasal canula (HFNC) served as useful alternatives to invasive mechanical ventilatory support for acute respiratory failure (ARF) during the peak of the SARS-CoV-2/COVID-19 pandemic. Unlike NiPPV, HFNC is a newer modality and its role in the treatment of patients with severe ARF is not yet clearly defined. Furthermore, the characteristics of responders versus non-responders to HFNC have not been determined. Although recent evidence indicates that many patients with ARF treated with HFNC survive without needing intubation, those who fail and are subsequently intubated have worse outcomes. Given that prolonged use of HFNC in patients with ARF might exacerbate patient self-inflicted lung injury, we hypothesized that among those patients with ARF due to COVID-19 pneumonia, prolonged HFNC beyond 24 h before intubation would be associated with increased in-hospital mortality.

Methods: This was a retrospective, multicenter, observational cohort study of 2720 patients treated for ARF secondary to SARS-CoV-2/COVID-19 pneumonia and initially managed with HFNC within the Banner Health system during the period from March 1^st, 2020, to July 31^st2021. In the subgroup of patients for went from HFNC to IMV, we assessed the effect of the duration of HFNC prior to intubation on mortality.

Abstract and Introduction
Methods
Results
Discussion
Conclusions
References

Table 1. Comparison by duration of HFNC (less than 24 h versus greater than 24 h) for patients with ARF due to COVID-19 pneumonia who failed HFNC and were subsequently intubated
	LESS THAN 24H	OVER 24H	TOTAL	P VALUES
TOTAL PATIENT VOLUME	432	896	1328
AVG. AGE (STD DEV)	63 (14.9)	65 (13)	64 (13.68)	0.0002
SEX (MALE), N (%)	246 (56.9)	544 (60.7)	790 (59.5)	0.19
COPD, N (%)	131 (30.3)	301 (33.6)	432 (32.5)	0.23
HF, N (%)	113 (26.2)	170 (19)	283 (21.3)	0.003
DM, N (%)	133 (30.8)	239 (26.7)	372 (28)	0.12
CKD, N (%)	101 (23.4)	211 (23.6)	312 (23.5)	0.95
HTN, N (%)	300 (69.4)	633 (70.7)	933 (70.3)	0.65
≥ 1 COMORBIDITY, N (%)	372 (86.1)	752 (83.9)	1124 (84.6)	0.30
TROPONIN (> 28NG/L), N (%)	93 (21.5)	161 (18)	254 (19.1)	0.12
CREATININE (> 1.5 MG/DL), N (%)	85 (19.7)	168 (18.8)	253 (19.1)	0.69
CRP (> 100 MG/L), N (%)	132 (30.6)	275 (30.7)	407 (30.7)	0.96
LYMPHOCYTES (< = 1 ML), N (%)	243 (56.3)	545 (60.8)	788 (59.3)	0.32
NT-PROBNP (> 88PG/ML), N (%)	132 (30.6)	269 (30)	401 (30.2)	0.84

Table 1. Comparison of covariates: age, sex, comorbidities (COPD, HF, DM, CKD, hypertension), baseline laboratory values (CRP [> 100 mg/L or < = 100 mg/L], Troponin I [> 28 ng/L or < = 28 ng/L], NT–proBNP [> 88 pg/mL or < = 88 pg/mL], Lymphocyte Count [> = 1.0 μL or < 1.0 μL] and Creatinine [< = 1.5 mg/dL or > 1.5 mg/dL]), by duration of HFNC (less than 24 h vs. greater than 24 h)

Table 2. Univariate analysis for 30-day in-hospital mortality among patients with ARF due to COVID-19 pneumonia who failed in HFNC and were subsequently intubated
		MORTALITY (%)	OR (95% CI)	P VALUES
SEX	Male	64.7	1.44 (1.15, 1.80)	0.0013
SEX	Female	56
AGE (YEARS)	≥ 50	66.5	4.42 (3.19, 6.10)	< .0001
AGE (YEARS)	18—49	31
COPD	Yes	60.7	0.97 (0.77, 1.23)	0.8
COPD	No	61.4
HF	Yes	64.3	1.19 (0.90, 1.56)	0.22
HF	No	60.3
DM	Yes	66.4	1.37 (1.06, 1.76)	0.014
DM	No	59.1
HTN	Yes	62.6	1.23 (0.96, 1.56)	0.095
HTN	No	57.7
CKD	Yes	71.8	1.85 (1.41, 2.44)	< .0001
CKD	No	57.9
TROPONIN (NG/L)	> 28	70.9	1.7 (1.26, 2.29)	0.0004
TROPONIN (NG/L)	≤ 28	58.9
CREATININE (MG/DL)	> 1.5	75.1	2.2 (1.61, 2.99)	< .0001
CREATININE (MG/DL)	≤ 1.5	57.9
CRP (MG/L)	> 100	59	0.88 (0.69, 1.11)	0.28
CRP (MG/L)	≤ 100	62.1
LYMPHOCYTES (ML)	≤ 1	62.2	0.82 (0.63, 1.07)	0.14
LYMPHOCYTES (ML)	> 1	57.4
NT-PROBN (PG/ML)	> 88	63.6	1.16 (0.91, 1.48)	0.23
NT-PROBN (PG/ML)	≤ 88	60.1
HFNC DURATION	> 24 h	67.2	2.16 (1.71, 2.74)	< .0001
HFNC DURATION	≤ 24 h	48.6

Table 2. Univariate analysis shows that among patients with COVID-19 ARF who failed HFNC and were intubated; male sex, older age, prior diagnosis of diabetes mellitus (DM), a history of chronic kidney disease (CKD), elevated high sensitivity troponin, elevated serum creatinine and prolonged duration of HFNC prior to intubation were all associated with increased in-hospital mortality

Table 3. Multivariate analysis for 30-day in-hospital mortality among patients with ARF due to COVID-19 pneumonia who failed in HFNC and were subsequently intubated
COVARIATES		OR (95% CI)	P-VALUES
SEX	Male vs Female	1.34 (1.06, 1.70)	0.016
AGE	≥ 50 vs 18 ~ 49	3.92 (2.79, 5.50)	< .0001
DM	Yes, vs No	0.92 (0.65, 1.26)	0.54
CKD	Yes, vs No	1.50 (1.04, 2.18)	0.03
HTN	Yes, vs No	1.02 (0.78, 1.32)	0.91
TROPONIN (NG/L)	> 28 vs ≤ 28	1.30 (0.92, 1.82)	0.14
CREATININE (MG/DL)	> 1.5 vs ≤ 1.5	1.65 (1.14, 2.38)	0.008
CRP	> 100 vs < = 100	0.83 (0.64, 1.08)	0.16
NT-PROBNP	> 88 vs < = 88	0.91 (0.70, 1.19)	0.51
HFNC DURATION	> 24 h vs ≤ 24 h	2.08 (1.63, 2.67)	< .0001

Table 3, multivariate logistic regression with the covariates sex, age, DM, CKD, HTN, serum troponin, serum creatinine, CRP, NT-PROBNP, and HFNC duration included in the final model based on previously published associations and the univariate logistic regression results

processing....

Delayed Intubation Associated With In-hospital Mortality in Patients With COVID-19 Respiratory Failure who Fail Heated and Humified High Flow Nasal Canula

Abstract and Introduction

Abstract

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

Email This

Feedback