Many observational studies have suggested that NHF prevents intubation. The clinical impression was unequivocally demonstrated in a large randomized trial (
Of note, the data is less conclusive in patients with hematological or oncological disorders.
If the question is interpreted as "Is it reasonable to start NHF and perhaps escalate to invasive ventilation in a patient beyond 65 years", the answer is yes, but patients and family must be informed that the prognosis is much less favorable than in younger patients. My bias is that intubation should be discussed on an individual basis above 70-75, depending on the presence of comorbodities and the fitness of the patient before being infected by Covid.
Yes, for at least two reasons. First, although there is - at a cohort level - a relationship between the importance of lung involvement and outcome, on an individual basis, we have sometimes had very rapid recovery despite an initial unfavorable radiological assessment. Second, the radiological phenotype also plays a role (we had the impression that very diffuse ground glass was less "bad" than consolidation display). And finally, even if the patient is at high risk of intubation, NHF can be initiated and will help preoxygenate the patient, and will serve as apneic oxygenation during laryngoscopy.
I don't yet have any personal experience with 100 l/min. My bias is that because there is a linear relationship between flow and both positive pressure and deadspace washout, this suggests that beneficial effects of NHF are more important at 100 l/min than at 60. Obviously, the question of tolerance is a key issue. We need more data on the tolerance of these very high flows.
This is a vast question and whole consensus conferences have been dedicated to this unique question. Bear in mind several facts: 1) there is no 100%-sure test or group of parameters that predict safe extubation; 2) reintubation will occur in 10%-20% of patients; 3) unplanned extubation does not systematically lead to reintubation (only 40% approx.). That means we as clinicians must stay very humble as to our capacity to predict extubation outcome. Always perform either a T-piece trial or minimal pressure support spontaneous breathing trial. When to start these trials? Partial or complete resolution of the cause that led to intubation. Hemodynamic stability without vasopressors, FiO2 < 40%, PEEP < 5, no or little neurological and cognitive impairment, appropriate cough, no or little muscle weakness.
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