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Decreased intubation risk with high-flow nasal cannula oxygen for COVID-19 respiratory failure (SOHO-COVID)
Clinical Question
Does the use of high-flow nasal cannula oxygen, compared with standard oxygen therapy via mask, reduce mortality in patients with respiratory failure due to COVID-19?
Bottom line
In patients with acute respiratory failure due to COVID-19, the use of HFNC, as compared with standard oxygen therapy, leads to decreased intubation at day 28 but has no effect on mortality. These results confirm data from a previous trial. You would need to treat 13 such patients with HFNC to prevent one additional intubation. Given an overestimation of expected deaths during study design, this trial did not have adequate power to detect a difference in mortality if one truly exists. 1b-
Reference
Study design: Randomized controlled trial (nonblinded)
Funding: Industry + govt
Setting: Inpatient (any location)
Synopsis
A previous trial showed oxygen delivered by high-flow nasal cannula (HFNC) led to fewer intubations and shorter clinical recovery time, but no change in mortality, in patients with respiratory failure due to COVID-19. In this multicenter study from France, investigators randomized adults hospitalized with respiratory failure due to COVID-19 to receive HFNC or standard oxygen therapy. In the HFNC group (n = 357), oxygen was delivered at 50 L per minute or more through a heated humidifier to maintain oxygen saturation of 92%-96%. In the standard oxygen therapy group (n = 354), oxygen was delivered through a nonrebreathing mask at 10 L per minute or more to achieve the same goal. Patients received their respective oxygen therapy for at least 48 hours. Baseline characteristics were similar in the 2 groups (mean age 61 years, 70% were men), except for a slightly lower PaO2 in the HFNC group (73 mmHg vs 76 mmHg; P = .03). No significant difference was detected in mortality rates at day 28 (10% in HFNC group vs 11% in the standard oxygen group; P = .60). However, fewer deaths occurred than were expected, resulting in an underpowered study. For secondary outcomes, the rate of intubation at day 28 was significantly lower in the HFNC group (45% vs 53% in standard oxygen group; hazard ratio 0.77; 95% CI 0.63 - 0.96; P = .03). There were no differences in intensive care unit or hospital lengths of stay.
Reviewer
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL
Comments
High flow nasal cannula O2 can help avoid intubation
This is important information. Intubation carries huge risks.
Decreased intubation risk with HFNC O2.
The author states the study was underpowered to detect a difference in mortality (10% HFNC vs 11% standard O2) given a fewer overall deaths than expected. The find the observed difference statistically significant would have taken a study of thousands of subject and probably far more than the study was meant to include. Being pragmatic, (statistical power or not) I think it is fair to conclude there is no difference in mortality between the two treatment modalities.
high flow nasal oxygen in Covid
decreases intubation but no change in mortality