Supplementation of High Velocity Nasal Insufflation with a Nonrebreather Mask for Severe Hypoxemic Respiratory Failure in Adult Patients with COVID-19

Whittle, Jessica S.; Sethi, Jigme; Volakis, Leonithas I.; Greenberg, Jeremy

doi:https://doi.org/10.1155/2022/5004108

Case Reports in Critical Care

On this page

Abstract Introduction Discussion Conclusion Data Availability Conflicts of Interest References Copyright Related Articles

Case Report | Open Access

Volume 2022 | Article ID 5004108 | https://doi.org/10.1155/2022/5004108

Supplementation of High Velocity Nasal Insufflation with a Nonrebreather Mask for Severe Hypoxemic Respiratory Failure in Adult Patients with COVID-19

Jessica S. Whittle,^1,2Jigme Sethi,³Leonithas I. Volakis,⁴and Jeremy Greenberg³

Academic Editor: Kenneth S. Waxman

Received25 Nov 2021

Accepted12 May 2022

Published24 May 2022

Abstract

The unique clinical features of COVID-19-related acute hypoxemic respiratory failure, as well as the widespread impact leading to resource strain, have led to reconsiderations of classic approaches to respiratory support. HFNO includes high flow nasal cannula (HFNC) and high velocity nasal insufflation (HVNI). There are currently no widely accepted criteria for HFNO failure. We report a series of three patients who experienced COVID-19-related acute severe hypoxemic respiratory failure. Each patient was initially managed with HVNI and had a ROX , suggesting HFNO failure was likely. They were subsequently managed with a nonrebreather mask (NRM) overlying and in combination with HVNI at maximal settings and were able to be managed without the need for invasive mechanical ventilation.

1. Introduction

The unique clinical features of COVID-19-related acute hypoxemic respiratory failure, as well as the widespread impact leading to resource strain, have led to reconsiderations of classic approaches to respiratory support. During the early phase of the COVID-19 pandemic, high flow nasal oxygen (HFNO) was seldom used due to concerns of aerosol production and possible harm from delayed intubation. The technology has subsequently been shown to be safe [1–3], and there is emerging evidence suggesting use of HFNO is associated with decreased mortality [4], reduced need for intubation, increase in ventilator-free days, and reduced ICU length of stay [5–10]. HFNO is currently recommended for acute hypoxemic respiratory failure not responsive to low-flow oxygen by the Society of Critical Care Medicine, Surviving Sepsis Campaign, and European Society of Intensive Medicine [11].

HFNO includes high flow nasal cannula (HFNC) and high velocity nasal insufflation (HVNI). HFNO systems provide oxygen-rich, heated, humidified gas to the patient’s nose at supraphysiologic flows sufficient to deliver a constant, precisely set high FiO₂ [12, 13]. HFNC flow rates reach up to 60 L/min, whereas HVNI delivers similar quantities of oxygen at flow rates up to 40 L/min due to increased velocity derived from a lower flow with a higher level of kinetic energy in the delivered gas. Both technologies facilitate rapid deadspace flush [14] Exhalation is to the open air in all HFNO therapies. Mechanistically, HFNO provides high FiO2, reduces dead space, provides low levels of PEEP [15], and decreases breathing frequency and work of breathing [13].

There are currently no widely accepted criteria for HFNO failure. However, patients who require vasopressor support [16, 17] and whose respiratory rate and thoracoabdominal asynchrony are not rapidly relieved with HFNO are potentially at high risk of HFNO failure [18]. The “ROX Index” was developed to aid in the prediction of clinical outcomes of hypoxemic patients treated with HFNO. It is calculated as the ratio of SpO₂/FiO₂ to respiratory rate (RR). A , measured at 12 hours after treatment initiation, suggests the patient is unlikely to progress to mechanical ventilation (hazard ratio: 0.273, ) [16, 19]. A suggests HFNO failure is likely and intubating the patient should be strongly considered [19]. The ROX index has been subsequently utilized and found to correlate with need for mechanical ventilation in patients with COVID-19 [20, 21].

We report a series of three patients who experienced COVID-19-related acute severe hypoxemic respiratory failure. Each patient was initially managed with HVNI (40 L/min max) and had a , suggesting HFNO failure was likely. They were subsequently managed with a nonrebreather mask (NRM) overlying and in combination with HVNI at maximal settings and were able to be managed without the need for invasive mechanical ventilation. In an effort to avoid respiratory suppression, sedating medications were avoided with the exception of minimal narcotic pain control provided as needed. No written consent has been obtained from the patients as there is no patient identifiable data included in this case report.

1.1. Patient 1

A 57-year-old female with a past medical history of diabetes and hypertension presented to the Emergency Department (ED) complaining of abdominal pain and diarrhea for 7 days, with cough, fever, and myalgia. Initial vital signs were temperature of 39.1°C, heart rate of 104 beats per minute (bpm), blood pressure of 143/64 mmHg, respiratory rate of 17 breaths per minute, and oxygen saturation of 89% on room air. She appeared nontoxic and was speaking in full sentences. Laboratory evaluation was unremarkable, and nasopharyngeal PCR testing for SARS-CoV-2 virus was positive. Chest X-ray showed patchy airspace disease.

Her hypoxemia was initially managed with supplemental oxygen at 3 L/min via nasal cannula (NC). On hospital day 2, she had a rapid clinical decline. HVNI and self-proning were initiated due to O₂ sat (78%) on 6 L NC. After HVNI, her respiratory rate subsequently decreased to 28 breaths per minute and her O₂ sat improved to 90%.

By day 5, the patient’s hypoxemia had progressively worsened despite maximal settings until her O₂ sat was 83% (). The patient expressed she did not want intubation unless as the “last resort” though acknowledged feeling “exhausted” from high work of breathing. An attempt was made to honor her wishes by placing a NRM at 15 L/min over the HVNI cannula. Her oxygen saturation improved to 92%, and her respiratory rate decreased to 25 breaths per minute. This therapy stabilized the patient and continued for 3 more days followed by progressive deescalation until she was discharged home on day 16 without supplemental oxygen.

1.2. Patient 2

A 42-year-old male with no medical history presented to the ED with 5 days of dyspnea with fevers, chills, and nonproductive cough. Vital signs were temperature of 38.1°C, heart rate of 116 bpm, blood pressure of 100/61 mmHg, respiratory rate of 32 breaths per minute, and oxygen saturation of 47% on room air. He appeared ill and distressed. Despite critical hypoxemia, he was able to speak in truncated sentences, and his lungs were clear to auscultation. The remainder of his exam was unremarkable.

Laboratory evaluation revealed leukocytosis and elevated C-reactive protein, D-dimer, and aminotransferases. An ABG showed pH 7.38, PaCO₂ 29, and PaO₂ 31. Chest X-ray showed bilateral, perihilar, and basilar airspace disease, and PCR testing was positive for SARS-CoV-2. Treatment with HVNI was initiated at 40 L/min and FiO₂ 90%. His oxygen saturation improved to 90% (ROX ).

On day 3, his oxygen saturation decreased to 84% despite FiO₂ of 100%. Clinically, he was in extremis. Nonetheless, the patient requested to delay mechanical ventilation so that he could continue video chats with his family. To honor the patient’s wishes, additional oxygen was administered from a NRM at 15 L/min placed over the HVNI cannula. His oxygen saturation improved to 93%, and he reported subjective improvement in his respiratory effort.

On day 5, the patient improved and was weaned to 30 L/min and FiO₂ of 70%. Then on day 7, he again deteriorated and HVNI was escalated back to maximal support. Computed tomographic (CT) pulmonary angiography of the chest revealed multifocal, bilateral, ground-glass opacities, and dense consolidation, as well as multiple segmental and subsegmental pulmonary emboli. Despite HVNI, his oxygen saturation was 87%. To again avoid mechanical ventilation, a NRM was successfully used in conjunction with NVNI. Therapy continued, and the patient improved until day 17, when HVNI was discontinued, and supplemental oxygen was given through a nasal cannula at 10 L/min. His ICU course was then complicated by life-threatening epistaxis and delirium. The patient required an additional 10 days of hospitalization until he was discharged home on day 36 without the need for supplemental oxygen.

1.3. Patient 3

A 37-year-old female gravida 6 para 5 at 40 weeks estimated gestational age with no medical history presented to the obstetrics triage unit with contractions. Two weeks prior, she asymptomatically tested positive for the SARS-CoV-2 virus on routine testing. She had no viral symptoms but was admitted due to signs and symptoms concerning for acute fatty liver of pregnancy and preeclampsia. Due to fetal distress, she underwent emergent cesarean section and was extubated without difficulty. Her immediate postoperative course was uncomplicated. Her liver function tests and coagulation profile improved following delivery.

On hospital day 2, she developed mild hypoxemia and radiographic multifocal airspace disease. By day 4, she developed rapidly progressive respiratory failure with hypoxemia. Her oxygen saturation on 9 L/min was 81%, and respiratory rate was 43 breaths per minute. She was then escalated to HVNI at 40 L/min and FiO₂ of 100%. Her oxygen saturation improved to 88%, and her respiratory rate decreased to 36 breaths per minute (ROX ).

A trial of additional supplemental oxygen through a NRM at 15 L/min placed over HVNI was performed, and her oxygen saturation improved to 94%. Her respiratory rate decreased to 32 breaths per minute. She steadily improved, and respiratory support was slowly weaned until she was discharged home on hospital day 11 without need for supplemental oxygen.

2. Discussion

COVID-19 has intermittently caused a worldwide resource-challenged health systems, and HFNO has become a widespread recommended therapy for select patients [22]. Recommendations for management of COVID-19-related acute severe hypoxemic respiratory failure have some agreement in that low-flow oxygen therapy should be utilized first, followed by HFNO or NIPPV (if HFNO is not first available), and then to consider intubation with a lung-protective ventilation strategy of low tidal volume with sufficient PEEP for lung recruitment [2] [23]. However, patients that refuse intubation or situations in which ventilators become limited represent a more challenging scenario.

This report provides a series of cases, wherein COVID-19 patients with severe acute hypoxemic respiratory failure were clinically stabilized with a NRM utilized in conjunction with HVNI. This dual-modality treatment option provided positive patient clinical outcomes without the need for intubation, while simultaneously respecting patient autonomy. On a broader note, this represents a simple, relevant, and successful treatment option for patients with severe respiratory failure that should be further researched. Based on the perceived positive outcome for these three patients, this approach has become routinely adopted in our institution for patients with COVID-19-related acute severe hypoxemic respiration failure.

Nasal cannula interface with the nostril, ideally, was with an open architecture. Clinicians are generally instructed to allow for at least half of the area of the nare to remain unoccluded by the nasal prong of the HVNI cannula interface. This opening permits a free flow of exhaled gas from the patient, important to facilitate flush of the accessible extra-thoracic nasal/pharyngeal deadspace. However, this open aperture also provides an opportunity for entrainment of room air (Bernoulli effect). This issue is not typically clinically significant. Groves and Tobin measured pressures with volunteers using high flow nasal cannulas and open and closed mouths [15]. The high flow of air into the small nasal chamber created measured elevations of nasal pressure linearly increasing with flow rate, which act to prevent entrainment of room air and create positive end expiratory pressure. However, the pressure rise was markedly attenuated when the mouth was open—as is true for many highly tachypneic patients—and this is the scenario in which entrainment of NRM 100% oxygen from the mouth and even the nose can be beneficial. The safety of such a configuration is not likely impacted, as the primary gas source for the patient is provided through the HVNI, which should be set to meet patient needs. The incorporation of a NRM would not negatively impact the washout effect of the high flow oxygen therapy, as the gas available at the mouth and nose for entrainment will be oxygen rich, and the mask is designed to flush exhaled gas as part of normal operation.

There has been much discussion about the possibility of worse outcomes for patients for whom mechanical intubation is delayed, largely based on two papers. The first, in 2015 by Kang et al., reports dramatically different mortality rates comparing patients who were intubated early in the course of critical illness versus late [24]. These findings were discussed at length in a review by Ricard, suggesting that confounding variables likely played a role in why the mortality rates reported in this paper seem more extreme than those reported in other studies [25, 26]. The second study by Miller et al. was a retrospective database analysis reporting that, amongst patients who failed primary therapy and later required mechanical ventilation, patients who had been primarily treated with HFNC had higher mortality than those treated with BiPaP [27]. Unfortunately, the sample sizes are extremely different (2,241 HFNC vs. 32,761 BiPaP), and the initial indications for treatment were not available for a majority of the patients in the HFNC group. These issues suggest that the practice pattern in this hospital system is extraordinarily biased towards the use of BiPaP. It is unknown whether the bias is a result of physician comfort, scientific opinion, supplies available, or patient population. It is impossible to know from the data reported whether the two patient groups were similar enough for comparison and it is important to note that the trend to higher mortality for treatment failures was not observed in all subgroups (i.e., patients with pneumonia). Nonetheless, these reports provide valuable indicators that the proper management of patients requiring respiratory is highly nuanced and much remains unclear.

In addition to a lack of benefit being identified from early intubation [28], a recent meta-analysis of 12 studies including 8944 critically ill patients with COVID-19 showed that there was no morbidity or mortality difference in and early vs. late intubation management strategy, thus concluding that a wait and see approach may yield fewer intubations [29].

Data from multiple regions and populations throughout the world have shown considerable variation in practice regarding the timing and strategy for mechanical ventilation of patients with COVID-19-related acute respiratory failure. Outcomes remain highly variable and likely multifactorial and an optimal strategy has yet to be fully elucidated [30–34]. For patients who decline intubation and mechanical ventilation, yet for whom aggressive care is not yet futile, utilization of a NRM with HVNI may be a consideration.

3. Conclusion

Patients with persistently high oxygen requirements often have prolonged clinical courses of illness, higher morbidity, and potentially higher mortality rates. Thus, it seems that the concept described in this work may be worthy of consideration in a select group of patients, particularly those for whom intubation and mechanical ventilation is not appropriate or desired for end-of-life care or in extreme environments in which respiratory support resources are limited.

Data Availability

All data are present in the manuscript.

Conflicts of Interest

JW became employed by Vapotherm, Inc. as VP of Clinical Research, after this manuscript was submitted. JG has served as a consultant to Vapotherm, Inc. within the last 3 years for the development of educational materials. LV is a Research Scientist with Vapotherm, Inc. JS has no disclosure.

References

S. Leonard, C. W. Atwood Jr., B. K. Walsh 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, vol. 158, no. 3, pp. 1046–1049, 2020.
View at: Publisher Site | Google Scholar
J. S. Whittle, I. Pavlov, A. D. Sacchetti, C. Atwood, and M. S. Rosenberg, “Respiratory support for adult patients with COVID-19,” Journal of the American College of Emergency Physicians Open, vol. 1, no. 2, pp. 95–101, 2020.
View at: Publisher Site | Google Scholar
S. Leonard, W. Strasser, J. S. Whittle et al., “Reducing aerosol dispersion by high flow therapy in COVID-19: high resolution computational fluid dynamics simulations of particle behavior during high velocity nasal insufflation with a simple surgical mask,” Journal of the American College of Emergency Physicians Open, vol. 1, no. 4, pp. 578–591, 2020.
View at: Publisher Site | Google Scholar
J. P. Frat, A. W. Thille, A. Mercat et al., “High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure,” The New England Journal of Medicine, vol. 372, no. 23, pp. 2185–2196, 2015.
View at: Publisher Site | Google Scholar
A. Demoule, A. Vieillard Baron, M. Darmon et al., “High-flow nasal cannula in critically III patients with severe COVID-19,” American Journal of Respiratory and Critical Care Medicine, vol. 202, no. 7, pp. 1039–1042, 2020.
View at: Publisher Site | Google Scholar
R. Mellado-Artigas, B. L. Ferreyro, F. Angriman et al., “High-flow nasal oxygen in patients with COVID-19-associated acute respiratory failure,” Critical Care, vol. 25, no. 1, p. 58, 2021.
View at: Publisher Site | Google Scholar
B. Rochwerg, D. Granton, D. X. Wang et al., “High flow nasal cannula compared with conventional oxygen therapy for acute hypoxemic respiratory failure: a systematic review and meta-analysis,” Intensive Care Medicine, vol. 45, no. 5, pp. 563–572, 2019.
View at: Publisher Site | Google Scholar
K. Nagata, T. Morimoto, D. Fujimoto et al., “Efficacy of high-flow nasal cannula therapy in acute hypoxemic respiratory failure: decreased use of mechanical ventilation,” Respiratory Care, vol. 60, no. 10, pp. 1390–1396, 2015.
View at: Publisher Site | Google Scholar
J. D. J. Plate, L. P. H. Leenen, M. Platenkamp, J. Meijer, and F. Hietbrink, “Introducing high-flow nasal cannula oxygen therapy at the intermediate care unit: expanding the range of supportive pulmonary care,” Trauma Surgery & Acute Care Open, vol. 3, no. 1, article e000179, 2018.
View at: Publisher Site | Google Scholar
W. Fascia, J. Pedley, and R. Acevedo, “Successful use of high flow nasal cannula outside of the critical care areas,” Chest, vol. 158, no. 4, p. A2285, 2020.
View at: Publisher Site | Google Scholar
W. Alhazzani, M. H. Møller, Y. M. Arabi et al., “Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19),” Intensive care medicine, vol. 46, no. 5, pp. 854–887, 2020.
View at: Publisher Site | Google Scholar
M. G. Drake, “High-flow nasal cannula oxygen in adults: an evidence-based assessment,” Annals of the American Thoracic Society, vol. 15, no. 2, pp. 145–155, 2018.
View at: Publisher Site | Google Scholar
M. Nishimura, “High-flow nasal cannula oxygen therapy in adults: physiological benefits, indication, clinical benefits, and adverse effects,” Respiratory Care, vol. 61, no. 4, pp. 529–541, 2016.
View at: Publisher Site | Google Scholar
T. L. Miller, B. Saberi, and S. Saberi, “Computational fluid dynamics modeling of extrathoracic airway flush: evaluation of high flow nasal cannula design elements,” Journal of Pulmonary & Respiratory Medicine, vol. 6, no. 5, 2016.
View at: Publisher Site | Google Scholar
N. Groves and A. Tobin, “High flow nasal oxygen generates positive airway pressure in adult volunteers,” Australian Critical Care, vol. 20, no. 4, pp. 126–131, 2007.
View at: Publisher Site | Google Scholar
J. Rello, M. Pérez, O. Roca et al., “High-flow nasal therapy in adults with severe acute respiratory infection: a cohort study in patients with 2009 influenza A/H1N1v,” Journal of Critical Care, vol. 27, no. 5, pp. 434–439, 2012.
View at: Publisher Site | Google Scholar
X. Yang, Y. Yu, J. Xu et al., “Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study,” Respiratory Medicine, vol. 8, no. 5, pp. 475–481, 2020.
View at: Publisher Site | Google Scholar
B. Sztrymf, J. Messika, F. Bertrand et al., “Beneficial effects of humidified high flow nasal oxygen in critical care patients: a prospective pilot study,” Intensive Care Medicine, vol. 37, no. 11, pp. 1780–1786, 2011.
View at: Publisher Site | Google Scholar
O. Roca, B. Caralt, J. Messika et al., “An index combining respiratory rate and oxygenation to predict outcome of nasal high-flow therapy,” American Journal of Respiratory and Critical Care Medicine, vol. 199, no. 11, pp. 1368–1376, 2019.
View at: Publisher Site | Google Scholar
L. A. Suliman, T. T. Abdelgawad, N. S. Farrag, and H. W. Abdelwahab, “Validity of ROX index in prediction of risk of intubation in patients with COVID-19 pneumonia,” Advances in Respiratory Medicine, vol. 89, no. 1, pp. 1–7, 2021.
View at: Publisher Site | Google Scholar
A. Gianstefani, G. Farina, V. Salvatore et al., “Role of ROX index in the first assessment of COVID-19 patients in the emergency department,” Internal and Emergency Medicine, vol. 16, no. 7, pp. 1959–1965, 2021.
View at: Publisher Site | Google Scholar
C. Crimi, P. Pierucci, T. Renda, L. Pisani, and A. Carlucci, “High-flow nasal cannula and COVID-19: a clinical review,” Respiratory Care, vol. 67, no. 2, pp. 227–240, 2022.
View at: Publisher Site | Google Scholar
S. Lentz, M. A. Roginski, T. Montrief, M. Ramzy, M. Gottlieb, and B. Long, “Initial emergency department mechanical ventilation strategies for COVID-19 hypoxemic respiratory failure and ARDS,” The American Journal of Emergency Medicine, vol. 38, no. 10, pp. 2194–2202, 2020.
View at: Publisher Site | Google Scholar
B. J. Kang, Y. Koh, C. M. Lim et al., “Failure of high-flow nasal cannula therapy may delay intubation and increase mortality,” Intensive Care Medicine, vol. 41, no. 4, pp. 623–632, 2015.
View at: Publisher Site | Google Scholar
J.-D. Ricard, O. Roca, V. Lemiale et al., “Use of nasal high flow oxygen during acute respiratory failure,” Intensive Care Medicine, vol. 46, no. 12, pp. 2238–2247, 2020.
View at: Publisher Site | Google Scholar
J. D. Ricard, J. Messika, B. Sztrymf, and S. Gaudry, “Impact on outcome of delayed intubation with high-flow nasal cannula oxygen: is the device solely responsible?” Intensive Care Medicine, vol. 41, no. 6, pp. 1157-1158, 2015.
View at: Publisher Site | Google Scholar
D. C. Miller, J. Pu, D. Kukafka, and C. Bime, “Failure of high flow nasal cannula and subsequent intubation is associated with increased mortality as compared to failure of non-invasive ventilation and mechanical ventilation alone: a real-world retrospective analysis,” Journal of Intensive Care Medicine, vol. 37, no. 1, pp. 41–45, 2022.
View at: Google Scholar
I. I. Siempos, E. Xourgia, T. K. Ntaidou et al., “Effect of early vs. delayed or no intubation on clinical outcomes of patients with COVID-19: an observational study,” Front Med (Lausanne), vol. 7, article 614152, 2020.
View at: Publisher Site | Google Scholar
E. Papoutsi, V. G. Giannakoulis, E. Xourgia, C. Routsi, A. Kotanidou, and I. I. Siempos, “Effect of timing of intubation on clinical outcomes of critically ill patients with COVID-19: a systematic review and meta-analysis of non-randomized cohort studies,” Critical Care, vol. 25, no. 1, p. 121, 2021.
View at: Publisher Site | Google Scholar
G. Grasselli, A. Zangrillo, A. Zanella et al., “Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region, Italy,” Jama, vol. 323, no. 16, pp. 1574–1581, 2020.
View at: Publisher Site | Google Scholar
D. Wang, B. Hu, C. Hu et al., “Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China,” Jama, vol. 323, no. 11, pp. 1061–1069, 2020.
View at: Publisher Site | Google Scholar
M. Arentz, E. Yim, L. Klaff et al., “Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington state,” Journal of the American Medical Association, vol. 323, no. 16, pp. 1612–1614, 2020.
View at: Publisher Site | Google Scholar
S. Richardson, J. S. Hirsch, M. Narasimhan et al., “Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the new York City area,” Journal of the American Medical Association, vol. 323, no. 20, pp. 2052–2059, 2020.
View at: Publisher Site | Google Scholar
C. Writing, “Effect of a lower vs higher positive end-expiratory pressure strategy on ventilator-free days in ICU patients without ARDS,” Journal of the American Medical Association, vol. 324, no. 24, pp. 2509–2520, 2020.
View at: Publisher Site | Google Scholar

Copyright

Copyright © 2022 Jessica S. Whittle et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

PDF Download Citation

Download other formats

Order printed copies