Non-rebreather mask and low-flow nasal cannula vs high-flow nasal cannula in severe COVID-19 pneumonia in the emergency department

Mohd Kamil MK 1 , Yuen Yoong KP 2 , Noor Azhar AM 3 , Bustam A 4 , Abdullah AH 5 , Md Yusuf MH 6 Show all authors , Zambri A 7 , Ahmad Zahedi AZ 8 , Shafie H 5

Affiliations 

  • 1 Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia. Electronic address: presisoc90@gmail.com
  • 2 Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia. Electronic address: khadijah.poh@ummc.edu.my
  • 3 Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia. Electronic address: muhaimin@um.edu.my
  • 4 Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia. Electronic address: aidabustam@um.edu.my
  • 5 Emergency and Trauma Department, Kuala Lumpur, Hospital, Kuala Lumpur, Malaysia
  • 6 Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia. Electronic address: hafyzuddin@ummc.edu.my
  • 7 Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia. Electronic address: nuraliyah@ummc.edu.my
  • 8 Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia. Electronic address: ahmadzulkarnain@ummc.edu.my
Am J Emerg Med, 2023 Jan;63:86-93.
PMID: 36327755 DOI: 10.1016/j.ajem.2022.10.029

Abstract

BACKGROUND: To assess the effectiveness of non-rebreather mask combined with low-flow nasal cannula (NRB + NC) compared to high-flow nasal cannula (HFNC) in improving oxygenation in patients with COVID-19-related hypoxemic respiratory failure (HRF).

METHODS: This retrospective study was conducted in emergency departments of two tertiary hospitals from June 1 to August 31, 2021. Consecutive patients aged >18 years admitted for COVID-19-related HRF (World Health Organization criteria: confirmed COVID-19 pneumonia with respiratory rate > 30 breaths/min, severe respiratory distress, or peripheral oxygen saturation < 90% on room air) requiring NRB + NC or HFNC were screened for enrollment. Primary outcome was improvement of partial pressure arterial oxygen (PaO2) at two hours. Secondary outcomes were intubation rate, ventilator-free days, hospital length of stay, and 28-day mortality. Data were analyzed using linear regression with inverse probability of treatment weighting (IPTW) based on propensity score.

RESULTS: Among the 110 patients recruited, 52 (47.3%) were treated with NRB + NC, and 58 (52.7%) with HFNC. There were significant improvements in patients' PaO2, PaO2/FIO2 ratio, and respiratory rate two hours after the initiation of NRB + NC and HFNC. Comparing the two groups, after IPTW adjustment, there were no statistically significant differences in PaO2 improvement (adjusted mean ratio [MR] 2.81; 95% CI -5.82 to 11.43; p = .524), intubation rate (adjusted OR 1.76; 95% CI 0.44 to 6.92; p = .423), ventilator-free days (adjusted MR 0.00; 95% CI -8.84 to 8.85; p = .999), hospital length of stay (adjusted MR 3.04; 95% CI -2.62 to 8.69; p = .293), and 28-day mortality (adjusted OR 0.68; 95% CI 0.15 to 2.98; p = .608).

CONCLUSION: HFNC may be beneficial in COVID-19 HRF. NRB + NC is a viable alternative, especially in resource-limited settings, given similar improvement in oxygenation at two hours, and no significant differences in long-term outcomes. The effectiveness of NRB + NC needs to be investigated by a powered randomized controlled trial.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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