Analysis finds noninvasive respiratory support for COVID-19 safe, may improve outcomes
Among patients with COVID-19-related acute respiratory failure, noninvasive respiratory support appears to be safe, effective and may yield better outcomes, according to an analysis published in The Lancet Respiratory Medicine.
In addition, authors of the personal view concluded that noninvasive respiratory support may reduce the need for intubation and improve resource utilization.
Sampath Weerakkody, BMBS, from the Centre for Human Health and Performance at the Institute of Sport, Exercise and Health at the University College London, and colleagues conducted an analysis of two randomized controlled trials and 83 observational studies that assessed the effects of high-flow nasal oxygen, CPAP and bilevel positive airway pressure (BiPAP) in patients with COVID-19. Across the studies, the patient population included 13,931 patients with COVID-19-related acute respiratory failure.
“Rising case numbers in China, Europe and the USA in the spring of 2020, allied with shortages of mechanical ventilators and ICU beds, led to noninvasive respiratory support being increasingly adopted outside ICUs, with guidelines altered accordingly,” the authors wrote. “Nonetheless, the role and benefits of CPAP and high-flow nasal oxygen in the management of COVID-19 remain contentious, with lively debates about the timing of intubation and the risk-benefit balance between patient self-inflicted lung injury and ventilator-induced lung injury.”
Overall, 5,120 patients from 40 studies were candidates for full treatment escalation, and the authors evaluated data from 4,669 patients. Data showed that 1,880 (37%) received invasive mechanical ventilation and 78% survived until the end of the studies. Median survival was similar across the noninvasive respiratory support modalities, at 79% for CPAP only, 83% for high-flow nasal oxygen only, 76% for BiPAP only and 78% for those who received CPAP, BiPAP or high-flow nasal oxygen.
There was a 29.8% survival rate among the 1,050 patients who received noninvasive respiratory support in 22 studies.
The two randomized controlled trials demonstrated superiority of noninvasive respiratory support in reducing the need for intubation compared with high-flow nasal oxygen. One randomized controlled trial showed similar hospital mortality among patients who received BiPAP or high-flow nasal oxygen, with significantly lower requirements for invasive ventilation among those receiving BiPAP (30% vs. 51%). The second trial showed superiority with CPAP but no benefits with high-flow nasal oxygen compared with conventional oxygen therapy in intubation requirements or death within 30 days.
According to the authors, international, collaborative and coordinated approaches are required when designing future prospective, randomized studies of noninvasive respiratory support modalities for COVID-19.
“Whether such objective criteria for the selection of patients who are likely to benefit from a trial of noninvasive respiratory support can be applied during periods of resource limitation is also worth examining in future studies to gauge the impact on outcomes of rationing interventions,” the authors wrote.
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