Comparing CPAP, HFNO, and Conventional Oxygen Therapy for Severe COVID-19

Continuous positive airway pressure (CPAP) reduces the risk of tracheal intubation or mortality compared with conventional oxygen therapy in COVID-19 patients with acute hypoxemic respiratory failure, according to a study published in the Journal of the American Medical Association.

Noninvasive respiratory strategies such as CPAP and high-flow nasal oxygen (HFNO) have been recommended for patients with COVID-19 with acute hypoxemic respiratory failure as a means of avoiding invasive mechanical ventilation. Nevertheless, concerns linger regarding whether these strategies serve to delay tracheal intubation and exacerbate lung injury for a proportion of patients.

To address these concerns, researchers conducted a clinical trial of 1273 patients at 48 hospitals across the United Kingdom to compare CPAP (n=380), HFNO (n=418), and conventional oxygen therapy (n=475) in patients hospitalized with COVID-19 with acute hypoxemic respiratory failure. The primary outcome was a composite of tracheal intubation or mortality within 30 days. The trial was conducted between April 2020 and May 2021, with final follow-up in June 2021.

Crossover between interventions occurred in 17.1% of participants (15.3% in the CPAP group; 11.5% in the HFNO group; 23.6% in the conventional oxygen therapy group). The researchers found that the need for tracheal intubation or mortality within 30 days was significantly lower with CPAP vs conventional oxygen therapy (36.3% vs 44.4%; P =.03), but not significantly different with HFNO vs conventional oxygen therapy (44.3% vs 45.1%; P =.83). Adverse events occurred in 34.2% of participants in the CPAP group, 20.6% in the HFNO group, and 13.9% in the conventional oxygen therapy group.

The researchers concluded, “Among patients with acute hypoxemic respiratory failure due to COVID-19, an initial strategy of CPAP significantly reduced the risk of tracheal intubation or mortality compared with conventional oxygen therapy, but there was no significant difference between an initial strategy of HFNO compared with conventional oxygen therapy.”

Researchers noted that this study was limited by the fact that it did not achieve its planned sample size and may thus have been underpowered to detect small but clinically important treatment effects.

Disclosure: This study was funded by the United Kingdom National Institute for Health Research. Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 

Reference

Perkins GD, Ji C, Connolly BA, et al; RECOVERY-RS Collaborators. 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(6):546–558. doi:10.1001/jama.2022.0028