High-flow nasal oxygen in resource-constrained, non-intensive, high-care wards for COVID-19 acute hypoxaemic respiratory failure: Comparing outcomes of the first v. third waves at a tertiary centre in South Africa
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Abstract
Background. High-flow nasal oxygen (HFNO) is an accepted treatment for severe COVID-19-related acute hypoxaemic respiratory failure (AHRF).
Objectives. To determine whether treatment outcomes at Groote Schuur Hospital, Cape Town, South Africa, during the third COVID-19 wave would be affected by increased institutional experience and capacity for HNFO and more restrictive admission criteria for respiratory high-care wards and intensive care units.
Methods. We included consecutive patients with COVID-19-related AHRF treated with HFNO during the first and third COVID-19 waves. The primary endpoint was comparison of HFNO failure (composite of the need for intubation or death while on HFNO) between waves.
Results. A total of 744 patients were included: 343 in the first COVID-19 wave and 401 in the third. Patients treated with HFNO in the first wave were older (median (interquartile range) age 53 (46 - 61) years v. 47 (40 - 56) years; p<0.001), and had higher prevalences of diabetes (46.9% v. 36.9%; p=0.006), hypertension (51.0% v. 35.2%; p<0.001), obesity (33.5% v. 26.2%; p=0.029) and HIV infection (12.5% v. 5.5%; p<0.001). The partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) ratio at HFNO initiation and the ratio of oxygen saturation/FiO2 to respiratory rate within 6 hours (ROX-6 score) after HFNO commencement were lower in the first wave compared with the third (median 57.9 (47.3 - 74.3) mmHg v. 64.3 (51.2 - 79.0) mmHg; p=0.005 and 3.19 (2.37 - 3.77) v. 3.43 (2.93 - 4.00); p<0.001, respectively). The likelihood of HFNO failure (57.1% v. 59.6%; p=0.498) and mortality (46.9% v. 52.1%; p=0.159) did not differ significantly between the first and third waves.
Conclusion. Despite differences in patient characteristics, circulating viral variant and institutional experience with HFNO, treatment outcomes were very similar in the first and third COVID-19 waves. We conclude that once AHRF is established in COVID-19 pneumonia, the comorbidity profile and HFNO provider experience do not appear to affect outcome.
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Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382(18):1708-1720. https//doi.org/0.1056/NEJMoa2002032 2. World Health Organization. Coronavirus disease pandemic 2020. https://www. euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/novel-
coronavirus-2019-ncov (accessed 25 July 2020).
Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395(10223):497-506. https//doi. org/10.1016/S0140-6736(20)30183-5
Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalised with COVID-19 in the New York City area. JAMA 2020;323(20):2052-2059. https//doi.org/10.1001/ jama.2020.6775
Sadoff J, Gray G, Vandebosch A, et al. Safety and efficacy of single-dose Ad26. COV2.S vaccine against Covid-19. N Engl J Med 2021;384(23):2187-2201. https// doi.org/10.1056/NEJMoa2101544
Burki T. Global COVID-19 vaccine inequity. Lancet Infect Dis 2021;21(7):922-923.
https//doi.org/10.1016/S1473-3099(21)00344-3
Islam S, Islam T, Islam MR. New coronavirus variants are creating more challenges to global healthcare system: A brief report on the current knowledge. Clin Pathol 2022;15:2632010X221075584. https//doi.org/10.1177/2632010X221075584
European Centre for Disease Prevention and Control. COVID-19 situation update worldwide. 2020. https://www.ecdc.europa.eu/en/covid-19 (accessed 2 September 2020).
World Health Organization. Media statement: Knowing the risks of COVID-19. 8 March 2020. https://www.who.int/indonesia/news/detail/08-03-2020-knowing-the- risk-for-covid-19 (accessed 23 February 2021).
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). Intensive Care Med 2020;46(5):854-887. https//doi.org/10.1007/s00134-020-06022-5
GroundUp.GrooteSchuuronthebrink.21May2020.https://www.groundup.org.za/ article/covid-19-groote-schuur-brink/ (accessed 2 September 2020).
Whittle JS, Pavlov I, Sacchetti AD, Atwood C, Rosenberg MS. Respiratory support for adult patients with COVID‐19. J Am Coll Emerg Physicians Open 2020;1(2):95-101. https//doi.org/10.1002/emp2.12071
Mauri T, Turrini C, Eronia N, et al. Physiologic effects of high-flow nasal cannula in acute hypoxemic respiratory failure. Am J Respir Crit Care Med 2017;195(9):1207- 1215. https//doi.org/10.1164/rccm.201605-0916OC
Frat JP, Coudroy R, Marjanovic N, Thille AW. High-flow nasal oxygen therapy and noninvasive ventilation in the management of acute hypoxemic respiratory failure. Ann Transl Med 2017;5(14):297. https//doi.org/10.21037/atm.2017.06.52
Xie J, Tong Z, Guan X, Du B, Qiu H, Slutsky AS. Critical care crisis and some recommendations during the COVID-19 epidemic in China. Intensive Care Med 2020;46(5):837-840. https//doi.org/10.1007/s00134-020-05979-7
Calligaro GL, Lalla U, Audley G, et al. The utility of high-flow nasal oxygen for severe COVID-19 pneumonia in a resource-constrained setting: A multi-centre prospective observational study. EClinicalMedicine 2020;28:100570. https://doi.org/10.1016/j. eclinm.2020.100570
Patel M, Gangemi A, Marron R, et al. Use of high flow nasal therapy to treat moderate to severe hypoxemic respiratory failure in COVID-19. BMJ Open Respir Res 2020;7(1):e000650. https://doi.org/10.1136/bmjresp-2020-000650
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. https//doi.org/10.1186/s12890-020-01354-w
Crimi C, Pierucci P, Renda T, Pisani L, Carlucci A. High-flow nasal cannula and COVID-19: A clinical review. Respir Care 2022;67(2):227-240. https//doi.org/10.4187/ respcare.09056
Mellado-Artigas R, Ferreyro BL, Angriman F, et al. High-flow nasal oxygen in patients with COVID-19-associated acute respiratory failure. Crit Care 2021;25(1):58. https// doi.org/10.1186/s13054-021-03469-w
Mendelson M, Boloko L, Boutall A, et al. Clinical management of COVID-19: Experiences of the COVID-19 epidemic from Groote Schuur Hospital, Cape Town, South Africa. S Afr Med J 2020;110(10):973-981. https//doi.org/10.7196/SAMJ.2020. v110i10.15157
Von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. PLoS Med 2007;4(10):e296. https//doi.org/10.1371/ journal.pmed.0040296
Van Zyl Smit RN, Pai M, Yew WW, et al. Global lung health: The colliding epidemics of tuberculosis, tobacco smoking, HIV and COPD. Eur Respir J 2010;35(1):27-33. https//doi.org/10.1183/09031936.00072909
National Institute for Communicable Diseases. Proposed definition of COVID-19 wave in South Africa. Communicable Diseases Communiqué 2021;20(11):3-4 https://www.nicd.ac.za/wp-content/uploads/2021/11/Proposed-definition-of- COVID-19-wave-in-South-Africa.pdf (accessed 7 September 2022).
Johns Hopkins University of Medicine. Coronavirus Resource Center. South Africa overview. https://coronavirus.jhu.edu/region/south-africa (accessed 22 January 2023).
RECOVERY Collaborative Group; Horby P, Lim WS, Emberson JR, et al. Dexamethasone in hospitalised patients with Covid-19. N Engl J Med 2021;384(8):693- 704. https//doi.org/10.1056/NEJMoa2021436
Bekker LG, Garrett N, Goga A, et al. Effectiveness of the Ad26.COV2.S vaccine in health-care workers in South Africa (the Sisonke study): Results from a single-arm, open-label, phase 3B, implementation study. Lancet 2022;399(10330):1141-1153. https//doi.org/10.1016/S0140-6736(22)00007-1
Roca O, Caralt B, Messika J, et al. An index combining respiratory rate and oxygenation to predict outcome of nasal high-flow therapy. Am J Respir Crit Care Med 2019;199(11):1368-1376. https//doi.org/10.1164/rccm.201803-0589OC
Goh KJ, Chai HZ, Ong TH, et al. Early prediction of high flow nasal cannula therapy outcomes using a modified ROX index incorporating heart rate. J Intensive Care 2020;8):41. https://doi.org/10.1186/s40560-020-00458-z
Centers for Disease Control and Prevention. Stay up to date with your COVID-19 vaccines. 2022. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to- date.html (accessed 17 April 2022).
IBM. SPSS Statistics for Mac, version 28.0.1.0 (142). Armonk, NY: IBM Corp., 2021. https://www.ibm.com/support/pages/downloading-ibm-spss-statistics-28010 (accessed 27 October 2022).
Western Cape Department of Health. Western Cape Critical Care Triage Tool. 2020. https://datacartographer.com/covid/#/ (accessed 14 December 2022).
Dave JA, Tamuhla T, Tiffin N, et al. Risk factors for COVID-19 hospitalisation and death in people living with diabetes: A virtual cohort study from the Western Cape Province, South Africa. Diabetes Res Clin Pract 2021;177:108925. https//doi. org/10.1016/j.diabres.2021.108925
NortierC.PhasetwoofCovidvaccineroll-outstartsoffbyprioritisingoldagehomes. Daily Maverick, 17 May 2021. https://www.dailymaverick.co.za/article/2021-05-17- phase-two-of-covid-vaccine-roll-out-starts-off-by-prioritising-old-age-homes/ (accessed 14 December 2022).
Burki TK. Lifting of COVID-19 restrictions in the UK and the Delta variant. Lancet Respir Med 2021;9(8):e85. https//doi.org/10.1016/S2213-2600(21)00328-3
Ward NS, Afessa B, Kleinpell R, et al. Intensivist/patient ratios in closed ICUs: A statement from the Society of Critical Care Medicine Taskforce on ICU Staffing. Crit Care Med 2013;41(2):638-645. https//doi.org/10.1097/CCM.0b013e3182741478
Attaway AH, Scheraga RG, Bhimraj A, Biehl M, Hatipoglu U. Severe covid-19 pneumonia: Pathogenesis and clinical management. BMJ 2021;372:n436. https//doi. org/10.1136/bmj.n436
Zuo M, Huang Y, Ma W, et al. Expert recommendations for tracheal intubation in critically ill patients with novel coronavirus disease 2019. Chin Med Sci J 2020;35(2):105-109. https//doi.org/10.24920/003724
Cook TM, El-Boghdadly K, McGuire B, et al. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists, the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia 2020;75(6):785-799. https://doi.org/10.1111/anae.15054
Brown CA, Mosier JM, Carlson JN, Gibbs MA. Pragmatic recommendations for intubating critically ill patients with suspected COVID‐19. J Am Coll Emerg Physicians Open 2020;1(2):80-84. https//doi.org/10.1002/emp2.12063
Marini JJ, Gattinoni L. Management of COVID-19 respiratory distress. JAMA 2020;323(22):2329-2330. https://doi.org/10.1001/jama.2020.6825
Vera M, Kattan E, Born P, et al. Intubation timing as determinant of outcome in patients with acute respiratory distress syndrome by SARS-CoV-2 infection. J Crit Care 2021;65:164-169. https://doi.org/10.1016/j.jcrc.2021.06.008
Papoutsi E, Giannakoulis VG, Xourgia E, Routsi C, Kotanidou A, Siempos II. Effect of timing of intubation on clinical outcomes of critically ill patients with COVID-19: A systematic review and meta-analysis of non-randomised cohort studies. Crit Care 2021;25(1):121. https://doi.org/10.1186/s13054-021-03540-6
Thomson D, Calligaro, G. Timing of intubation in COVID-19: Not just location, location, location? Crit Care 2021;25:193. https://doi.org/10.1186/s13054-021-03617-2