Conventional oxygen therapy versus CPAP as a ceiling of care in ward-based patients with COVID-19: a multi-centre cohort evaluation

P Bradley, J Wilson, R Taylor, J Nixon, J Redfern, P Whittemore, M Gaddah, K Kavuri, A Haley, P Denny, C Withers, R C Robey, C Logue, N Dahanayake, D Siaw Hui Min, J Coles, M S Deshmukh, S Ritchie, M Malik, H AbdelaalK Sivabalah, M D Hartshorne, D Gopikrishna, A Ashish, E Nuttall, A Bentley, T Bongers, T Gatheral, T W Felton, N Chaudhuri, L Pearmain

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Abstract

BACKGROUND: Continuous positive airway pressure (CPAP) therapy is commonly used for respiratory failure due to severe COVID-19 pneumonitis, including in patients deemed not likely to benefit from invasive mechanical ventilation (nIMV). Little evidence exists demonstrating superiority over conventional oxygen therapy, whilst ward-level delivery of CPAP presents practical challenges. We sought to compare clinical outcomes of oxygen therapy versus CPAP therapy in patients with COVID-19 who were nIMV.

METHODS: This retrospective multi-centre cohort evaluation included patients diagnosed with COVID-19 who were nIMV, had a treatment escalation plan of ward-level care and clinical frailty scale ≤ 6. Recruitment occurred during the first two waves of the UK COVID-19 pandemic in 2020; from 1st March to May 31st, and from 1st September to 31st December. Patients given CPAP were compared to patients receiving oxygen therapy that required FiO2 ≥0.4 for more than 12 hours at hospitals not providing ward-level CPAP. Logistic regression modelling was performed to compare 30-day mortality between treatment groups, accounting for important confounders and within-hospital clustering.

FINDINGS: Seven hospitals provided data for 479 patients during the UK COVID-19 pandemic in 2020. Overall 30-day mortality was 75.6% in the oxygen group (186/246 patients) and 77.7% in the CPAP group (181/233 patients). A lack of evidence for a treatment effect persisted in the adjusted model (adjusted odds ratio 0.84 95% CI 0.57-1.23, p=0.37). 49.8% of patients receiving CPAP-therapy (118/237) chose to discontinue it.

INTERPRETATION: No survival difference was found between using oxygen alone or CPAP to treat patients with severe COVID-19 who were nIMV. A high patient-initiated discontinuation rate for CPAP suggests a significant treatment burden. Further reflection is warranted on the current treatment guidance and widespread application of CPAP in this setting.

FUNDING: L Pearmain is supported by the MRC (MR/R00191X/1). TW Felton is supported by the NIHR Manchester Biomedical Research Centre.

Original languageEnglish
Article number101122
Pages (from-to)1-8
Number of pages8
JournalEClinicalMedicine
Volume40
Early online date8 Sep 2021
DOIs
Publication statusPublished (in print/issue) - 31 Oct 2021

Bibliographical note

© 2021 The Authors.

Keywords

  • COVID-19
  • Non-invasive ventilation
  • Oxygen
  • nIMV
  • Invasive mechanical ventilation
  • Ceiling of care

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