Prediction of outcome of nasal high flow use during COVID-19-related acute hypoxemic respiratory failure
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LETTER
Prediction of outcome of nasal high flow use during COVID‑19‑related acute hypoxemic respiratory failure Noémie Zucman1, Jimmy Mullaert2, Damien Roux3, Oriol Roca4, Jean‑Damien Ricard1* and Contributors © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Dear Editor, In the course of Coronavirus Disease 2019 (COVID19)-related acute hypoxemic respiratory failure (AHRF), nasal high flow (NHF) has been initially seldom used [1]. Reassessment of environmental contamination risk progressively led to broader NHF application [2, 3]. Our purpose was to evaluate the ROX index [4], defined as the ratio of SpO2/FiO2 to respiratory rate (RR), as an early marker of NHF response and a potential predictor of its failure in the ICU setting. In this single-center retrospective study, all 18-year-old or older patients admitted to the ICU during the peak of the COVID-19 outbreak were screened for eligibility. Participants presenting with AHRF related to SARS-CoV-2 infection (confirmed by molecular testing) and treated with NHF as first-line ventilatory support were included. Patients’ characteristics and NHF-related data were collected from admission until NHF weaning or intubation which defined NHF failure. The ROX index was recorded several times daily. Local Ethics Committee approved the study. Participants were informed of the research’s purpose and their right to decline participation. Statistical analysis included association between early response to NHF [i.e., the latest value of the ROX index within the first 4 h after NHF initiation (ROX-H0H4)] and risk for intubation (Cox’s model for patients still at risk at H4).
*Correspondence: jean‑[email protected] 1 Assistance Publique‑Hôpitaux de Paris, DMU ESPRIT, Médecine Intensive Réanimation, Medico‑Surgical ICU, Louis Mourier Hospital, 92700 Colombes, France Full author information is available at the end of the article
The Contributors are listed in the acknowledgements section.
Maximization of the Youden’s index led to an optimal cut-off of the ROX index to predict NHF outcome. Among all 116 consecutive patients admitted to ICU from March 8 to April 16, 2020, 32 were not COVID19-related, 20 were intubated prior to admission and 2 declined participation. Median age of the study population (N = 62) was 55 (IQR 48–63). Patients presented with profound hypoxemia at NHF initiation [median FiO2 and S pO2 were 0.8 (IQR 0.6–1) and 96% (IQR 94–98), respectively] with median RR of 25 breaths per minute (IQR 21–32). Initial NHF settings were: F iO2: 0.8 (0.6–1) and gas flow: 50 L/min (40–60). Twenty-one patients (34%) succeeded on NHF and were discharged from ICU, whereas 39 (63%) required MV and 2 (3%) died while under NHF because of do-not-intubate order (they were excluded from further analysis). Overall ICU mortality was 17%. Median time to intubation was 10 h (95% CI 7–57). Kaplan–Meier estimates of risk for intubation (N = 60) is illustrated in Fig. 1. Median ROX-H0H4 was 5.4 (IQR 3.9–7.1). In Cox’s model, ROX-H0H4 ≥ 5.37 was significantly associate
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