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Einsatz der High Flow Therapie bei COVID-19-bedingtem akutem hypoxämischem Atemversagen

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Autor: Aude Garnero, Intensivist, Hôpital Sainte Musse, Toulon, France

Datum: 04.05.2021

Die High Flow Therapie (HFT) wird in der COVID-19-Pandemie häufig eingesetzt. Die veröffentlichen klinischen Erkenntnisse stammen zum Großteil aus retrospektiven Studien und beschreiben die wesentlichen Einstellungen sowie die Häufigkeit des Therapieversagens.
Einsatz der High Flow Therapie bei COVID-19-bedingtem akutem hypoxämischem Atemversagen

Einstellungen

Bei diesen Studien lag die Floweinstellung zu Beginn der HFT zwischen 30 l/min und 60 l/min (1-9). Der Sauerstoffwert betrug zwischen 60 % und 100 % bei Therapiebeginn (Hu M, Zhou Q, Zheng R, et al. Application of high-flow nasal cannula in hypoxemic patients with COVID-19: a retrospective cohort study. BMC Pulm Med. 2020;20(1):324. Published 2020 Dec 24. doi:10.1186/s12890-020-01354-w1​, Zucman N, Mullaert J, Roux D, Roca O, Ricard JD; Contributors. Prediction of outcome of nasal high flow use during COVID-19-related acute hypoxemic respiratory failure. Intensive Care Med. 2020;46(10):1924-1926. doi:10.1007/s00134-020-06177-15​) und wurde entsprechend dem SpO2-Zielwert auf über 90 % angepasst (Xu J, Yang X, Huang C, et al. A Novel Risk-Stratification Models of the High-Flow Nasal Cannula Therapy in COVID-19 Patients With Hypoxemic Respiratory Failure. Front Med (Lausanne). 2020;7:607821. Published 2020 Dec 8. doi:10.3389/fmed.2020.6078212​, Montiel V, Robert A, Robert A, et al. Surgical mask on top of high-flow nasal cannula improves oxygenation in critically ill COVID-19 patients with hypoxemic respiratory failure. Ann Intensive Care. 2020;10(1):125. Published 2020 Sep 29. doi:10.1186/s13613-020-00744-x8​).
Die Temperatur war auf einen Wert zwischen 31 °C und 37 °C eingestellt (2, Patel M, Gangemi A, Marron R, et al. Retrospective analysis of high flow nasal therapy in COVID-19-related moderate-to-severe hypoxaemic respiratory failure. BMJ Open Respir Res. 2020;7(1):e000650. doi:10.1136/bmjresp-2020-0006504​, Panadero C, Abad-Fernández A, Rio-Ramirez MT, et al. High-flow nasal cannula for Acute Respiratory Distress Syndrome (ARDS) due to COVID-19. Multidiscip Respir Med. 2020;15(1):693. Published 2020 Sep 16. doi:10.4081/mrm.2020.6937​, 8). Der Flow wird üblicherweise so eingestellt, dass er das Minutenvolumen des Patienten abdeckt, und wird danach entsprechend der Toleranz des Patienten angepasst. Die Sauerstoffeinstellung wird dynamisch basierend auf den SpO2-Werten und der Blutgasanalyse angepasst. Die Temperatur wird entsprechend dem Patientenkomfort eingestellt. Es gilt jedoch: je höher die Temperatur, desto höher die bereitgestellte Feuchtigkeit.

Klinisches Protokoll

1. Wann soll die HFT gestartet werden?
Wenn ein COVID-19-Patient trotz konventioneller Sauerstofftherapie hypoxämisch bleibt, legen Empfehlungen nahe, anstelle der konventionellen Sauerstofftherapie die HFT einzusetzen (Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med. 2020;48(6):e440-e469. doi:10.1097/CCM.000000000000436310​).

2. Grundeinstellungen:

  • Flow = 60 l/min
  • Temperatur = 37 °C für eine optimale Feuchtigkeit
  • Sauerstoff = 100 %


3. Anpassungen:

  • Der Sauerstoffwert sollte entsprechend dem SpO2-Zielwert zwischen 92 % und 96 % angepasst werden (10).
  • Spülen Sie vor jeder Mobilisierung mit Sauerstoff (Sauerstoff wird für 2 Minuten auf 100 % eingestellt).
  • Bei einem derart hohen Flow wird eine Temperatureinstellung von 37 °C üblicherweise gut vertragen.
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Entwöhnung

4. Wie wird der Patient von der HFT entwöhnt?

  • Wenn sich der Zustand des Patienten stabilisiert hat (d. h. 12 Stunden bei einer Sauerstoffeinstellung von 50 %), versuchen Sie, den Flow auf 50 l/min zu reduzieren. 
  • Wenn der Patient 40 % Sauerstoff erhält, senken Sie den Flow auf 40 l/min.
  • Versuchen Sie, die HFT jeden Tag abzusetzen, wenn die Sauerstoffzufuhr weniger als 40 % beträgt und der Flow unter 40 l/min liegt. 
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Adjuvante Behandlungen

Bei einer Sauerstoffzufuhr über 50 % kann die HFT mit der Bauchlage oder CPAP kombiniert werden.

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Fußnoten

Referenzen

  1. 1. Hu M, Zhou Q, Zheng R, et al. Application of high-flow nasal cannula in hypoxemic patients with COVID-19: a retrospective cohort study. BMC Pulm Med. 2020;20(1):324. Published 2020 Dec 24. doi:10.1186/s12890-020-01354-w
  2. 2. Xu J, Yang X, Huang C, et al. A Novel Risk-Stratification Models of the High-Flow Nasal Cannula Therapy in COVID-19 Patients With Hypoxemic Respiratory Failure. Front Med (Lausanne). 2020;7:607821. Published 2020 Dec 8. doi:10.3389/fmed.2020.607821
  3. 4. Patel M, Gangemi A, Marron R, et al. Retrospective analysis of high flow nasal therapy in COVID-19-related moderate-to-severe hypoxaemic respiratory failure. BMJ Open Respir Res. 2020;7(1):e000650. doi:10.1136/bmjresp-2020-000650
  4. 5. Zucman N, Mullaert J, Roux D, Roca O, Ricard JD; Contributors. Prediction of outcome of nasal high flow use during COVID-19-related acute hypoxemic respiratory failure. Intensive Care Med. 2020;46(10):1924-1926. doi:10.1007/s00134-020-06177-1
  5. 7. Panadero C, Abad-Fernández A, Rio-Ramirez MT, et al. High-flow nasal cannula for Acute Respiratory Distress Syndrome (ARDS) due to COVID-19. Multidiscip Respir Med. 2020;15(1):693. Published 2020 Sep 16. doi:10.4081/mrm.2020.693
  6. 8. Montiel V, Robert A, Robert A, et al. Surgical mask on top of high-flow nasal cannula improves oxygenation in critically ill COVID-19 patients with hypoxemic respiratory failure. Ann Intensive Care. 2020;10(1):125. Published 2020 Sep 29. doi:10.1186/s13613-020-00744-x
  7. 10. Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med. 2020;48(6):e440-e469. doi:10.1097/CCM.0000000000004363

Application of high-flow nasal cannula in hypoxemic patients with COVID-19: a retrospective cohort study.

Hu M, Zhou Q, Zheng R, et al. Application of high-flow nasal cannula in hypoxemic patients with COVID-19: a retrospective cohort study. BMC Pulm Med. 2020;20(1):324. Published 2020 Dec 24. doi:10.1186/s12890-020-01354-w



BACKGROUND

It had been shown that High-flow nasal cannula (HFNC) is an effective initial support strategy for patients with acute respiratory failure. However, the efficacy of HFNC for patients with COVID-19 has not been established. This study was performed to assess the efficacy of HFNC for patients with COVID-19 and describe early predictors of HFNC treatment success in order to develop a prediction tool that accurately identifies the need for upgrade respiratory support therapy.

METHODS

We retrospectively reviewed the medical records of patients with COVID-19 treated by HFNC in respiratory wards of 2 hospitals in Wuhan between 1 January and 1 March 2020. Overall clinical outcomes, the success rate of HFNC strategy and related respiratory variables were evaluated.

RESULTS

A total of 105 patients were analyzed. Of these, 65 patients (61.9%) showed improved oxygenation and were successfully withdrawn from HFNC. The PaO2/FiO2 ratio, SpO2/FiO2 ratio and ROX index (SpO2/FiO2*RR) at 6h, 12h and 24h of HFNC initiation were closely related to the prognosis. The ROX index after 6h of HFNC initiation (AUROC, 0.798) had good predictive capacity for outcomes of HFNC. In the multivariate logistic regression analysis, young age, gender of female, and lower SOFA score all have predictive value, while a ROX index greater than 5.55 at 6 h after initiation was significantly associated with HFNC success (OR, 17.821; 95% CI, 3.741-84.903 p<0.001).

CONCLUSIONS

Our study indicated that HFNC was an effective way of respiratory support in the treatment of COVID-19 patients. The ROX index after 6h after initiating HFNC had good predictive capacity for HFNC outcomes.

A Novel Risk-Stratification Models of the High-Flow Nasal Cannula Therapy in COVID-19 Patients With Hypoxemic Respiratory Failure.

Xu J, Yang X, Huang C, et al. A Novel Risk-Stratification Models of the High-Flow Nasal Cannula Therapy in COVID-19 Patients With Hypoxemic Respiratory Failure. Front Med (Lausanne). 2020;7:607821. Published 2020 Dec 8. doi:10.3389/fmed.2020.607821

Background: High-flow nasal cannula (HFNC) has been recommended as a suitable choice for the management of coronavirus disease 2019 (COVID-19) patients with acute hypoxemic respiratory failure before mechanical ventilation (MV); however, delaying MV with HFNC therapy is still a dilemma between the technique and clinical management during the ongoing pandemic. Methods: Retrospective analysis of COVID-19 patients treated with HFNC therapy from four hospitals of Wuhan, China. Demographic information and clinical variables before, at, and shortly after HFNC initiation were collected and analyzed. A risk-stratification model of HFNC failure (the need for MV) was developed with the 324 patients of Jin Yin-tan Hospital and validated its accuracy with 69 patients of other hospitals. Results: Among the training cohort, the median duration of HFNC therapy was 6 (range, 3-11), and 147 experienced HFNC failure within 7 days of HFNC initiation. Early predictors of HFNC failure on the basis of a multivariate regression analysis included age older than 60 years [odds ratio (OR), 1.93; 95% confidence interval (CI), 1.08-3.44; p = 0.027; 2 points], respiratory rate-oxygenation index (ROX) <5.31 (OR, 5.22; 95% CI, 2.96-9.20; p < 0.001; 5 points) within the first 4 h of HFNC initiation, platelets < 125 × 109/L (OR, 3.04; 95% CI, 1.46-6.35; p = 0.003; 3 points), and interleukin 6 (IL-6) >7.0 pg/mL (OR, 3.34; 95% CI, 1.79-6.23; p < 0.001; 3 points) at HFNC initiation. A weighted risk-stratification model of these predictors showed sensitivity of 80.3%, specificity of 71.2% and a better predictive ability than ROX index alone [area under the curve (AUC) = 0.807 vs. 0.779, p < 0.001]. Six points were used as a cutoff value for the risk of HFNC failure stratification. The HFNC success probability of patients in low-risk group (84.2%) was 9.84 times that in the high-risk group (34.8%). In the subsequent validation cohort, the AUC of the model was 0.815 (0.71-0.92). Conclusions: Aged patients with lower ROX index, thrombocytopenia, and elevated IL-6 values are at increased risk of HFNC failure. The risk-stratification models accurately predicted the HFNC failure and early stratified COVID-19 patients with HFNC therapy into relevant risk categories.

Retrospective analysis of high flow nasal therapy in COVID-19-related moderate-to-severe hypoxaemic respiratory failure.

Patel M, Gangemi A, Marron R, et al. Retrospective analysis of high flow nasal therapy in COVID-19-related moderate-to-severe hypoxaemic respiratory failure. BMJ Open Respir Res. 2020;7(1):e000650. doi:10.1136/bmjresp-2020-000650

Invasive mechanical has been associated with high mortality in COVID-19. Alternative therapy of high flow nasal therapy (HFNT) has been greatly debated around the world for use in COVID-19 pandemic due to concern for increased healthcare worker transmission.This was a retrospective analysis of consecutive patients admitted to Temple University Hospital in Philadelphia, Pennsylvania, from 10 March 2020 to 24 April 2020 with moderate-to-severe respiratory failure treated with HFNT. Primary outcome was prevention of intubation. Of the 445 patients with COVID-19, 104 met our inclusion criteria. The average age was 60.66 (+13.50) years, 49 (47.12 %) were female, 53 (50.96%) were African-American, 23 (22.12%) Hispanic. Forty-three patients (43.43%) were smokers. Saturation to fraction ratio and chest X-ray scores had a statistically significant improvement from day 1 to day 7. 67 of 104 (64.42%) were able to avoid invasive mechanical ventilation in our cohort. Incidence of hospital-associated/ventilator-associated pneumonia was 2.9%. Overall, mortality was 14.44% (n=15) in our cohort with 13 (34.4%) in the progressed to intubation group and 2 (2.9%) in the non-intubation group. Mortality and incidence of pneumonia was statistically higher in the progressed to intubation group. CONCLUSION: HFNT use is associated with a reduction in the rate of invasive mechanical ventilation and overall mortality in patients with COVID-19 infection.

Prediction of outcome of nasal high flow use during COVID-19-related acute hypoxemic respiratory failure.

Zucman N, Mullaert J, Roux D, Roca O, Ricard JD; Contributors. Prediction of outcome of nasal high flow use during COVID-19-related acute hypoxemic respiratory failure. Intensive Care Med. 2020;46(10):1924-1926. doi:10.1007/s00134-020-06177-1

High-flow nasal cannula for Acute Respiratory Distress Syndrome (ARDS) due to COVID-19.

Panadero C, Abad-Fernández A, Rio-Ramirez MT, et al. High-flow nasal cannula for Acute Respiratory Distress Syndrome (ARDS) due to COVID-19. Multidiscip Respir Med. 2020;15(1):693. Published 2020 Sep 16. doi:10.4081/mrm.2020.693



INTRODUCTION

High-flow nasal cannula oxygen therapy (HFNC) has been shown to be a useful therapy in the treatment of patients with Acute Respiratory Distress Syndrome (ARDS), but its efficacy is still unknown in patients with COVID-19. Our objective is to describe its utility as therapy for the treatment of ARDS caused by SARS-CoV-2.

METHODS

A retrospective, observational study was performed at a single centre, evaluating patients with ARDS secondary to COVID-19 treated with HFNC. The main outcome was the intubation rate at day 30, which defined failure of therapy. We also analysed the role of the ROX index to predict the need for intubation.

RESULTS

In the study period, 196 patients with bilateral pneumonia were admitted to our pulmonology unit, 40 of whom were treated with HFNC due to the presence of ARDS. The intubation rate at day 30 was 52.5%, and overall mortality was 22.5%. After initiating HFNC, the SpO2/FiO2 ratio was significantly better in the group that did not require intubation (113.4±6.6 vs 93.7±6.7, p=0.020), as was the ROX index (5.0±1.6 vs 4.0±1.0, p=0.018). A ROX index less than 4.94 measured 2 to 6 h after the start of therapy was associated with increased risk of intubation (HR 4.03 [95% CI 1.18 - 13.7]; p=0.026).

CONCLUSION

High-flow therapy is a useful treatment in ARDS in order to avoid intubation or as a bridge therapy, and no increased mortality was observed secondary to the delay in intubation. After initiating HFNC, a ROX index below 4.94 predicts the need for intubation.

Surgical mask on top of high-flow nasal cannula improves oxygenation in critically ill COVID-19 patients with hypoxemic respiratory failure.

Montiel V, Robert A, Robert A, et al. Surgical mask on top of high-flow nasal cannula improves oxygenation in critically ill COVID-19 patients with hypoxemic respiratory failure. Ann Intensive Care. 2020;10(1):125. Published 2020 Sep 29. doi:10.1186/s13613-020-00744-x



OBJECTIVE

Critically ill patients admitted in ICU because of COVID-19 infection display severe hypoxemic respiratory failure. The Surviving Sepsis Campaign recommends oxygenation through high-flow nasal cannula over non-invasive ventilation. The primary outcome of our study was to evaluate the effect of the addition of a surgical mask on a high-flow nasal cannula system on oxygenation parameters in hypoxemic COVID-19 patients admitted in ICU who do not require urgent intubation. The secondary outcomes were relevant changes in PaCO2 associated with clinical modifications and patient's feelings.

DESIGN

We prospectively assessed 21 patients admitted in our mixed Intensive Care Unit of the Cliniques Universitaires Saint Luc.

MAIN RESULTS

While FiO2 was unchanged, we demonstrate a significant increase of PaO2 (from 59 (± 6), to 79 mmHg (± 16), p < 0.001), PaO2/FiO2 from 83 (± 22), to 111 (± 38), p < 0.001) and SaO2 (from 91% (± 1.5), to 94% (± 1.6), p < 0.001), while the patients were under the surgical mask. The SpO2 returned to pre-treatment values when the surgical mask was removed confirming the effect of the device rather than a spontaneous positive evolution.

CONCLUSION

A surgical mask placed on patient's face already treated by a High-flow nasal cannula device improves COVID-19 patient's oxygenation admitted in Intensive Care Unit for severe hypoxemic respiratory failure without any clinically relevant side.

Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19).

Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med. 2020;48(6):e440-e469. doi:10.1097/CCM.0000000000004363



BACKGROUND

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed.

METHODS

We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations.

RESULTS

The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which four are best practice statements, nine are strong recommendations, and 35 are weak recommendations. No recommendation was provided for six questions. The topics were: 1) infection control, 2) laboratory diagnosis and specimens, 3) hemodynamic support, 4) ventilatory support, and 5) COVID-19 therapy.

CONCLUSION

The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new evidence in further releases of these guidelines.

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High flow therapy in COVID-19 pneumonia

High-flow therapy (HFT) is a non-invasive form of respiratory support that can lower the intubation rate and mortality in patients with acute hypoxemic respiratory failure (AHRF) (1). Driven by concerns about the exposure of healthcare workers, initial recommendations discouraged the use of HFT in COVID-19 patients (2, 3).