Clinical question: What is the role of continuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) compared to conventional oxygen therapy in the management of COVID-19-related acute hypoxemic respiratory failure?
Background: COVID-19 pulmonary manifestations range from pneumonitis to life-threatening acute respiratory distress syndrome (ARDS) necessitating tracheal intubation. Non-invasive oxygenation strategies are widely used in non-COVID respiratory-failure processes including congestive heart failure and chronic obstructive pulmonary disease, however, their effects on reducing mortality or preventing intubation in severe COVID-19 are not clear.
Study design: Parallel-group, open-label, randomized clinical trial
Setting: Forty-eight acute care hospitals in the U.K. and Jersey.
Synopsis: The 1,273 RECOVERY-RS trial enrollees were randomized to CPAP, HFNO, and conventional oxygen therapy. Inclusion criteria were known or suspected COVID-19 with acute hypoxemic respiratory failure, SPO2 of 94% or less despite a fraction of inspired oxygen of at least 0.40, and suitability for tracheal intubation if required. An initial strategy of CPAP, compared with conventional oxygen therapy, significantly reduced the composite outcome of tracheal intubation or mortality within 30 days (36% versus 44%, P=0.03). In contrast, there was no significant difference between HFNO and conventional oxygen therapy (44% versus 45%, P=0.83). This decrease in the incidence of the primary outcome was attributable to a lower need for tracheal intubation in the CPAP group. Neither HFNO nor CPAP reduced mortality as compared with conventional oxygen therapy. A major study limitation is the absence of blinding as well as the lack of standardization of the tracheal intubation threshold.
Bottom line: CPAP significantly reduced the need for tracheal intubation compared to conventional oxygen therapy, whereas HFNO did not. However, no significant decrease in 30-day mortality between conventional oxygen therapy and non-invasive strategies was found.
Citation: Perkins GD, et al. Effect of noninvasive respiratory strategies on intubation or mortality among patients with acute hypoxemic respiratory failure and COVID-19: The Recovery-RS randomized clinical trial. JAMA 2022;327:546. doi: 10.1001/jama.2022.0028.
Dr. Ndzana is a hospital medicine physician at Maine Medical Center, Portland, Maine.