The outbreak of a novel coronavirus (2019-nCoV)-infected pneumonia (NCIP) is currently ongoing in China. Most of the critically ill patients received high-flow nasal cannula (HFNC) oxygen therapy. However, the experience of HFNC in this population is lacking.
We retrospectively screened 318 confirmed patients with NCIP in two hospitals of Chongqing, China, from January 1st to March 4th, 2020. Among them, 27 (8.4%) patients experienced severe acute respiratory failure including 17 patients (63%) treated with HFNC as first-line therapy, 9 patients (33%) treated with noninvasive ventilation (NIV) and one patient (4%) treated with invasive ventilation. HFNC failure was defined by the need of NIV or intubation as rescue therapy.
Of the 17 HFNC patients, 7 (41%) experienced HFNC failure. The HFNC failure rate was 0% (0/6) in patients with PaO2/FiO2 > 200 mm Hg vs. 63% (7/11) in those with PaO2/FiO2 ≤ 200 mm Hg (p = 0.04). Compared with baseline data, the respiratory rate significantly decreased after 1–2 h of HFNC in successful group [median 26 (IQR: 25–29) vs. 23 (22–25), p = 0.03]. However, it did not in the unsuccessful group. After initiation of NIV as rescue therapy among the 7 patients with HFNC failure, PaO2/FiO2 significantly improved after 1–2 h of NIV [median 172 (150–208) mmHg vs. 114 (IQR: 79–130) under HFNC, p = 0.04]. However, two out of seven (29%) patients with NIV as rescue therapy ultimately received intubation. Among the 27 patients with severe acute respiratory failure, four patients were eventually intubated (15%).
Our study indicated that HFNC was the most common ventilation support for patients with NCIP. Patients with lower PaO2/FiO2 were more likely to experience HFNC failure
To the best of our knowledge, there were no studies to report the use of HFNC in patients with NCIP. Our study originally reported that HFNC was the most common ventilation strategies for NCIP patients. Patients with lower PaO2/FiO2 were more likely to experience HFNC failure. Forty-one percent of patients required NIV as rescue therapy. However, 29% of NIV patients ultimately received intubation.
In our study, we found that the number of HFNC patients were much higher than NIV patients when the HFNC or NIV was used as an initial oxygen support. It means that physicians were more likely to use HFNC among the critically ill patients caused by NCIP. As the outbreak of NCIP in China, thousands of clinical staff joined in the patient management. Most of them had no experience on how to use HFNC or NIV. The current knowledge shows that (1) the HFNC is non-inferior to NIV on intubation rate in critically ill patients; (2) the use of HFNC is more comfortable than NIV and the skin breakdown is less likely to occur; and (3) the manipulation of HFNC is much easier than NIV. Therefore, the clinical staff were more likely to use HFNC in NCIP patients.
Person-to-person transmission of NCIP has been confirmed. In the early stages, the epidemic doubled in size every 7.4 days, and the estimated basic reproductive number was 2.2 (95% CI 1.4 to 3.9). The virus is believed transmitted mostly via droplets or contact and possibly via aerosol. All people are generally susceptible to the virus. As of February 11, 2020, 1716 clinical staff have been infected with NCIP, and 5 of them died. Therefore, a device that produces lesser number of droplets or aerosol is required. The exhaled air dispersion produced by HFNC was limited and the risk of hospital-acquired infection did not increase. Therefore, the use of HFNC in NCIP patients is feasible. However, the amount of condensation in the circuit increased when the ambient temperature decreased. The condensed water became an important source of infection for NCIP. So, avoidance or reduction of condensation was very important when the HFNC was used.
A previous study reported that 38% of HFNC patients required intubation. In this study, 13% of patients experienced HFNC failure and required NIV as rescue therapy. Among the NIV patients who experienced HFNC failure, the intubation rate was 64%. However, in our study, 41% of patients experienced HFNC failure. Among the unsuccessful patients, all of them directly switched to NIV (no one directly switched to intubation). It means that the physicians who managed the NCIP patients were more likely to use NIV than intubation when the HFNC was unable to maintain the oxygenation. We speculated that the process of intubation made the physicians at high risk of infection because of the close encounter and irritable cough. However, among the patients with HFNC failure in our study, only 29% received intubation. This indicates that the success rate is high after transition to NIV.
Our study has several limitations. This is a retrospective observational study. We did not predefine how to manage the HFNC. The transition to NIV or intubation was decided by the attending physicians. Different physicians have different opinions on the point to switch to NIV or intubation. However, this study can reflect on how the HFNC has been used in the real world among the NCIP patients. In addition, we only enrolled 17 patients in this study as the enrollment period is short. To our knowledge, there are no studies that report on how the HFNC was used in NCIP patients. Rapid publication is very important for public health. It also can provide an important reference for clinical physicians when using HFNC in NCIP patients.
Conclusions This study firstly reports the experience of how to use HFNC in patients with NCIP. HFNC was the most common ventilation support for patients with NCIP. Patients with lower PaO2/FiO2 were more likely to experience HFNC failure. The overall rate of intubation was 15% among the NCIP patients with severe acute respiratory failure.
Reference & Source information: https://annalsofintensivecare.springeropen.com/
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