ABSTRACT
RATIONALE Acute hypoxemic respiratory failure (AHRF) is the major complication of coronavirus disease 2019 (COVID-19), yet optimal respiratory support strategies are uncertain. We aimed to describe outcomes with highflow oxygen delivered through nasal cannula (HFNC) and non-invasive positive pressure ventilation (NIPPV) in COVID-19 AHRF and identify individual factors associated with non-invasive respiratory support failure. METHODS We conducted a retrospective cohort study of hospitalized adults with COVID-19 within a large academic health system in New York City early in the pandemic to describe outcomes with HFNC and NIPPV. Patients were categorized into the HFNC cohort if they received HFNC but not NIPPV, whereas the NIPPV cohort included patients who received NIPPV with or without HFNC. We described rates of HFNC and NIPPV success, defined as live discharge without endotracheal intubation (ETI). Further, using Fine-Gray sub-distribution hazard models, we identified demographic and patient characteristics associated with HFNC and NIPPV failure, defined as the need for ETI and/or in-hospital mortality. RESULTS Of the 331 patients in the HFNC cohort, 154 (46.5%) patients were successfully discharged without requiring ETI. Of the 177 (53.5%) who experienced HFNC failure, 100 (56.5%) required ETI and 135 (76.3%) patients ultimately died. Among the 747 patients in the NIPPV cohort, 167 (22.4%) patients were successfully discharged without requiring ETI, and 8 (1.1%) were censored. Of the 572 (76.6%) patients who failed NIPPV, 338 (59.1%) required ETI and 497 (86.9%) ultimately died. In adjusted models, significantly increased risk of HFNC and NIPPV failure was observed among patients with co-morbid cardiovascular disease (sub-distribution hazard ratio (sHR) 1.82;95% confidence interval (CI), 1.17-2.83 and sHR 1.40;95% CI 1.06-1.84, respectively). Conversely, a higher oxygen saturation to fraction of inspired oxygen ratio (SpO2/FiO2) at HFNC and NIPPV initiation was associated with reduced risk of failure (sHR, 0.32;95% CI 0.19-0.54, and sHR 0.34;95% CI 0.21-0.55, respectively). CONCLUSIONS A subset of patients with COVID-19 AHRF was effectively managed with non-invasive respiratory modalities and achieved successful hospital discharge without requiring ETI. Notably, patients with co-morbid cardiovascular disease and more severe hypoxemia experienced lower success rates with both HFNC and NIPPV. Identification of specific patient factors may help inform more selective use of non-invasive respiratory strategies, and allow for a more personalized approach to the management of COVID-19 AHRF in pandemic settings.
ABSTRACT
RATIONALE: Patients discharged after hospitalization for COVID-19 pneumonia are at high risk for readmission and mortality. Early in the pandemic we noted that many patients discharged after initial improvement of their COVID pneumonia were subsequently readmitted with progressive hypoxemic respiratory failure. Therefore, we implemented a remote patient monitoring program to track pulse oximetry, heart rate and dyspnea after COVID- 19 hospitalization. The goal was twofold: to optimize hospital utilization and resources by expeditiously discharging stable patients and to improve patient safety after discharge with continued close monitoring at home. METHODS: Patients were eligible for 90-day remote monitoring if they were being discharged home, could access a smart phone and required supplemental oxygen during hospitalization. Enrolled patients received a Bluetooth enabled Nonin 3230 pulse oximeter and installed a mobile application provided by patientMpower, Ltd. for input of dyspnea symptoms. Patients were prompted to check oxygenation and input symptoms twice daily. Recorded data was transmitted to a monitoring portal;abnormal recordings triggered an alert;all data was reviewed by an APP (Advanced Practice Provider) and patients with alerts were contacted. Responses to alerts included change in medication regimen, adjustment of oxygen delivery, expedited follow-up visit scheduling, and emergency room referral. Remote monitoring data were reviewed at the scheduled post-discharge pulmonologist appointment. RESULTS: Between 4/28/20 and 11/30/20, 111 patients at Mount Sinai Hospital were enrolled in the remote monitoring program with 87 (78%) participants providing at least one entry. The mean age was 60 years (SD ± 14) and 59% were male. The median device usage was 84 days with 64% of patients reporting an oxygen saturation ≤ 91% during monitoring. 53% of patients reported at least one instance of dyspnea. There were on average 46.4 alerts per month with the majority stemming from oxygen saturations <95% and 49 outreach attempts a month. Table 1 summarizes these data. CONCLUSIONS: We describe the successful implementation of a remote monitoring program at a tertiary care center in NYC during the COVID-19 pandemic. Our subjective experience is that the ability to remotely monitor patients increased provider comfort when expediting discharges of medically stable patients. The program alerts reflected periods of worsening pulmonary status and triggered interactions that provided more continuous contact between providers and patients. Our next steps are to leverage the data from prolonged monitoring to gain insights into the recovery of COVID-19 patients and to determine factors associated with post discharge readmissions and mortality. .