Results of a nationwide survey on the use of non-invasive respiratory support in patients with respiratory failure due to COVID-19 infection

ABSTRACT

Introduction: Currently patients with COVID-19 related acute respiratory failure (ARF) may receive respiratory support with conventional oxygen therapy, high-flow nasal oxygen (HFNO) or continuous positive airway pressure (CPAP). A proportion of patients will subsequently require invasive ventilation. However, there is insufficient evidence on the relative effectiveness of different modes of noninvasive respiratory support (NIRS). In the absence of robust evidence to guide clinical decisions, there is likely significant variation in their use in UK practice. The RECOVERY-RS trial sought to address this knowledge gap, aiming to identify the most effective method of non-invasive respiratory support in COVID-19. This survey, conducted whilst RECOVERY-RS was in progress, sought to characterise the current use of NIRS in COVID-19 patients across the UK. Methods: An anonymous, online survey (10 questions) was distributed via national networks and professional societies. Healthcare professionals involved in managing COVID-19 patients were invited to participate with responses collected over two months from September to October 2020. Results: Of 145 respondents, the majority were critical care (60%) or respiratory (27%) clinicians. Prior to the COVID-19 pandemic, most reported having commonly used HFNO (89%) or CPAP (70%) for infection-related ARF. A small minority (3% HFNO vs 9% CPAP) reported no previous experience of their use. In COVID-19 patients suitable for intubation and ventilation, 92% of respondents had used CPAP and 61% HFNO to bridge to or prevent intubation. Conversely, 5% reported they would never use CPAP and 8% would never use HFNO as a bridge to intubation. 68% of clinicians chose CPAP as their personal preferred method of NIRS vs 26% HFNO when treating COVID-19 patients. In patients not suitable for invasive ventilation, CPAP was also more frequently used than HFNO (92% vs 61%). 37% worked in trusts enrolled in the RECOVERY-RS trial and the majority (59%) felt that RECOVERY-RS was an important study, addressing a key unanswered research question. Conclusion: This survey identified that a variety of methods of NIRS are being used for COVID-19 patients in the UK. CPAP predominates as both a ceiling of care treatment and as a bridge to intubation. This appears to represent a change in practice compared to the management of infection-related ARF prior to the COVID-19 pandemic, despite a lack of evidence at that time to suggest superior efficacy of CPAP. The heterogeneous survey results support the need for evidence of the most effective NIRS in COVID-19 in order to deliver optimal and standardised treatment.