A retrospective validation of the effective and safe treatment of patients on general care wards with high velocity nasal insufflation therapy utilizing prognostic risk scores during COVID-19

Catherine Brenner, Josh Good,  Heather Pavlichko, Susan McDonald, Kathy Gerich, Amy Bergeski, Matthew S. Pavlichko

Abstract

Background

Non-invasive positive pressure ventilation (NIPPV) has been a traditional therapy for acute respiratory failure (ARF). However, the use of NIPPV during the COVID-19 pandemic was challenging, while the use of invasive mechanical ventilation produced poor outcomes. An alternative to NIPPV, high velocity nasal insufflation (HVNI) has shown promise in treating ARF effectively. 

Objective

This study evaluated whether HVNI can be used to treat ARF safely on the general care ward (GCW) during COVID-19 pandemic surges.

Methods

After introducing HVNI therapy to the facility, an evidence-based scoring system, Modified Early Warning Score (MEWS), was used to risk stratify patients and assist in assigning care level. Initial settings, demographic data, patient outcomes, and health care worker (HCW) virus conversion were measured throughout the study. Treatment failure was defined as the need for invasive mechanical ventilation (IMV) or NIPPV after HVNI therapy. MEWS and ROX index were compared retrospectively using the Pearson product-moment correlation coefficient to identify trends. The Welch two sample t-test (desired power of 90% with alpha=0.05) was used for demographic and outcome analysis. 

Results

Two hundred thirty-four patients were treated with HVNI. The GCW failure rate of 18.56% (n=31/167) was lower than the ICU failure rate of 37.31% (n=25/67) but not statistically significant (P 0.175). No elevated risk to patients or HCW was observed. Respiratory rate (GCW 24.85 vs. ICU 30.14; P <0.001), MEWS (GCW 2.34 vs. ICU 3.09; p=0.002), and ROX index (GCW 5.49 vs. ICU 4.68; P 0.002) assessments appear to be adequate predictors of HVNI failure. The Pearson product-moment coefficient comparing MEWS and ROX index identified a moderate negative correlation (-0.434; P <0.001).

Discussion

HVNI therapy is an effective alternative to NIPPV for treating patients with COVID-19 associated ARF. Using measures such as MEWS and/or ROX, strict patient monitoring, and HCW surveillance, HVNI can be safely utilized on the GCW. This has a direct impact when dealing with patient surges where ICU beds and resources are limited.  Additional studies are needed to further delineate these concepts.

Keywords

COVID-19, Non-invasive Positive Pressure Ventilation, Acute Respiratory Failure, High Flow Nasal Oxygen, High Velocity Nasal Insufflation, ICU Admission, General Care Ward, MEWS, ROX

References

1. Johns Hopkins University and Medicine. Coronavirus Resource Center: United States Overview, Daily COVID-19 Hospitalizations. Accessed on June 29, 2023 from coronavirus.jhu.edu/region/united-states.

2. Hess DR. The evidence for noninvasive positive-pressure ventilation in the care of patients in acute respiratory failure: A systematic review of the literature. Respir Care 2004; 49(7):810-829. PMID: 15222912

3.Carron M, Freo U, BaHammam AS, et al. Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials. British Journal of Anaesthesia 2013; 110(6): 896-914. https://doi.org/10.1093/bja/aet070 PMid:23562934

4. Vega ML, Pisani L. Nasal high flow oxygen in acute respiratory failure. Pulmonology 2021; 27(3): 240-247. https://doi.org/10.1016/j.pulmoe.2021.01.005 PMid:33589403

5. Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015; 372:2185-2196. https://doi.org/10.1056/NEJMoa1503326 PMid:25981908

6. Doshi P, Whittle JS, Bublewicz M, et al. High-velocity nasal insufflation in the treatment of respiratory failure: A randomized clinical trial. Ann Emerg Med 2018; 72(1):73-83.e5. https://doi.org/10.1016/j.annemergmed.2017.12.006 PMid:29310868

7. Plotnikow GA, Accoce M, Fredes S, et al. High-flow oxygen therapy application in chronic obstructive pulmonary disease patients with acute hypercapnic respiratory failure: A multicenter study. Crit Care Explor 2021; 3(2):e0337. https://doi.org/10.1097/CCE.0000000000000337 PMid:33615235 PMCid:PMC7886497

8. Monro-Someville T, Sim M, Ruddy J, et al. The effect of high-flow nasal cannula oxygen therapy on mortality and intubation in acute respiratory failure: A systematic review and meta-analysis. Crit Care Med 2017; 45(4):e449-e456. https://doi.org/10.1097/CCM.0000000000002091 PMid:27611978

9. Messika J, Ahmed KB, Gaudry S, et al. Use of high-flow nasal cannula oxygen therapy in subjects with ARDS: a 1-year observational study. Respir Care 2015; 60(2):162-169. https://doi.org/10.4187/respcare.03423 PMid:25371400

10. Nagata K, Morimoto T, Fujimoto D, et al. Efficacy of high-flow nasal cannula therapy in acute hypoxemic respiratory failure: decreased use of mechanical ventilation. Respir Care 2015; 60(10):1390-1396. https://doi.org/10.4187/respcare.04026 PMid:26106206

11. Nedel WL, Deutschendorf C, Moraes Rodrigues Filho E. High-flow nasal cannula in critically ill subjects with or at risk for respiratory failure: a systematic review and meta-analysis. Respir Care 2017; 62(1):123-132. https://doi.org/10.4187/respcare.04831 PMid:27879383

12. Vincent J-L, Sakr Y, Singer M, et al. for EPIC III Investigators. Prevalence and outcomes of infection among patients in intensive care units in 2017. JAMA 2020; 323(15):1478-1487. https://doi.org/10.1001/jama.2020.2717 PMid:32207816 PMCid:PMC7093816

13. Detsky ME, Harhay MO, Bayard DF, et al. Six-month morbidity and mortality among intensive care unit patients receiving life-sustaining therapy. A prospective cohort study. Ann Am Thorac Soc 2017; 14(10):1562-1570. https://doi.org/10.1513/AnnalsATS.201611-875OC PMid:28622004 PMCid:PMC5718567

14. Ely WE, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291(14):1753-1762. https://doi.org/10.1001/jama.291.14.1753 PMid:15082703

15. Kotfis K, Marra A, Ely WE. ICU delirium – a diagnostic and therapeutic challenge in the intensive care unit. Anaesthesiol Intensive Ther 2018; 60(2):128-140. https://doi.org/10.5603/AIT.a2018.0011 PMid:29882581

16. Prin M, Wunsch H. The role of stepdown beds in hospital care. Am J Respir Crit Care Med 2014; 190(11):1210-1216. https://doi.org/10.1164/rccm.201406-1117PP PMid:25163008 PMCid:PMC4315815

17. Phua J, Hashmi M, Haniffa R. ICU beds: less is more? Not sure. Intensive Care Med 2020; 46:1600-1602. https://doi.org/10.1007/s00134-020-06162-8 PMid:32572529 PMCid:PMC7306568

18. Jackson J, Spilman SK, Kingery LK, et al. Implementation of high-flow nasal cannula therapy outside the intensive care setting. Respir Care 2021; 66(3):357-365. https://doi.org/10.4187/respcare.07960 PMid:32843505

19. Ludikhuiz, J, Borgert M, Binnekade J, et al. Standardized measurement of the Modified Early Warning Score results in enhanced implementation of a rapid response system: A quasi-experimental study. Resuscitation 2014; 85(5):676-682. https://doi.org/10.1016/j.resuscitation.2014.02.009 PMid:24561029

20. Azimi I, Anzanpour A, Rahmani AM, et al. Self-aware Early Warning Score System for IoT-Based Personalized Healthcare. In: Giokas K, Bokor L, Hopfgartner F (eds) eHealth 360°. Lecture Notes of the Institute for Computer Sciences, Social Informatics and Telecommunications Engineering 2017; vol 181. Springer, Cham. https://doi.org/10.1007/978-3-319-49655-9_8. https://doi.org/10.1007/978-3-319-49655-9_8

21. Roca O, Messika J, Caralt B, et al. Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: The utility of the ROX index. J Critic Care 2016; 35(10):200-205. https://doi.org/10.1016/j.jcrc.2016.05.022 PMid:27481760

22. Shalaby HM, Mohamed HA. High-velocity nasal insufflation success assessment using ROX index in patients with acute respiratory failure. The Egyptian Journal of Chest Diseases and Tuberculosis 2023; 72(3):393-400. https://doi.org/10.4103/ecdt.ecdt_105_22

23. Whittle JS, Sethi J, Volakis LI, et al. Supplementation of high velocity nasal insufflation with a nonrebreather mask for severe hypoxemic respiratory failure in adult patients with COVID-19. Case Reports in Critical Care 2022; 5004108. https://doi.org/10.1155/2022/5004108 PMid:35656503 PMCid:PMC9155977

24. R Core Team (2023). R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing, Vienna, Austria. https://www.R-project.org/.

25. Leonard S, Atwood C, Walsh BK, et al. Preliminary findings on control of dispersion of aerosols and droplets during high-velocity nasal insufflation therapy using a simple surgical mask: implications for the high-flow nasal cannula. Chest 2020; 158(3):1046-1049. https://doi.org/10.1016/j.chest.2020.03.043 PMid:32247712 PMCid:PMC7130245

26. Chavarria AP, Lezama ES, Navarro MG, et al. High-flow nasal cannula therapy for hypoxemic respiratory failure in patients with COVID-19. Ther Adv Infect Dis 2021; 8:20499361211042959. https://doi.org/10.1177/20499361211042959 PMid:34497714 PMCid:PMC8419547

27. Metwaly A, Magdy D. High-velocity nasal insufflation therapy in patients with COVID-19 pneumonia. Eur Respir J 2021; 58(suppl 65). https://doi.org/10.1183/13993003.congress-2021.PA1083

28. Claudia Crimi C, Paola Pierucci P, Teresa Renda T, et al. High-flow nasal cannula and COVID-19: A Clinical review. Respir Care 2022; 67(2) 227-240. https://doi.org/10.4187/respcare.09056 PMid:34521762

29. Zucman N, Mullaert J, Roux D, et al. Prediction of outcome of nasal high flow use during COVID-19-related acute hypoxemic respiratory failure. Intensive Care Med 2020; 46(10):1924-1926. https://doi.org/10.1007/s00134-020-06177-1 PMid:32671470 PMCid:PMC7362315