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 Abdelaal; K Sivabalah; M D Hartshorne; D Gopikrishna; A Ashish; E Nuttall; A Bentley; T Bongers; T Gatheral; T W Felton; N Chaudhuri; L Pearmain

doi:10.1016/j.eclinm.2021.101122

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 language	English
Article number	101122
Pages (from-to)	1-8
Number of pages	8
Journal	EClinicalMedicine
Volume	40
Early online date	8 Sept 2021
DOIs	https://doi.org/10.1016/j.eclinm.2021.101122
Publication status	Published (in print/issue) - 31 Oct 2021

Bibliographical note

Keywords

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

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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10.1016/j.eclinm.2021.101122

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Cite this

Bradley, P., Wilson, J., Taylor, R., Nixon, J., Redfern, J., Whittemore, P., Gaddah, M., Kavuri, K., Haley, A., Denny, P., Withers, C., Robey, R. C., Logue, C., Dahanayake, N., Min, D. S. H., Coles, J., Deshmukh, M. S., Ritchie, S., Malik, M., ... Pearmain, L. (2021). Conventional oxygen therapy versus CPAP as a ceiling of care in ward-based patients with COVID-19: a multi-centre cohort evaluation. EClinicalMedicine, 40, 1-8. Article 101122. https://doi.org/10.1016/j.eclinm.2021.101122

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

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.",

keywords = "COVID-19, Non-invasive ventilation, Oxygen, nIMV, Invasive mechanical ventilation, Ceiling of care",

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

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language = "English",

volume = "40",

pages = "1--8",

journal = "EClinicalMedicine",

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Bradley, P, Wilson, J, Taylor, R, Nixon, J, Redfern, J, Whittemore, P, Gaddah, M, Kavuri, K, Haley, A, Denny, P, Withers, C, Robey, RC, Logue, C, Dahanayake, N, Min, DSH, Coles, J, Deshmukh, MS, Ritchie, S, Malik, M, Abdelaal, H, Sivabalah, K, Hartshorne, MD, Gopikrishna, D, Ashish, A, Nuttall, E, Bentley, A, Bongers, T, Gatheral, T, Felton, TW, Chaudhuri, N & Pearmain, L 2021, 'Conventional oxygen therapy versus CPAP as a ceiling of care in ward-based patients with COVID-19: a multi-centre cohort evaluation', EClinicalMedicine, vol. 40, 101122, pp. 1-8. https://doi.org/10.1016/j.eclinm.2021.101122

TY - JOUR

T1 - Conventional oxygen therapy versus CPAP as a ceiling of care in ward-based patients with COVID-19

T2 - a multi-centre cohort evaluation

AU - Bradley, P

AU - Wilson, J

AU - Taylor, R

AU - Nixon, J

AU - Redfern, J

AU - Whittemore, P

AU - Gaddah, M

AU - Kavuri, K

AU - Haley, A

AU - Denny, P

AU - Withers, C

AU - Robey, R C

AU - Logue, C

AU - Dahanayake, N

AU - Min, D Siaw Hui

AU - Coles, J

AU - Deshmukh, M S

AU - Ritchie, S

AU - Malik, M

AU - Abdelaal, H

AU - Sivabalah, K

AU - Hartshorne, M D

AU - Gopikrishna, D

AU - Ashish, A

AU - Nuttall, E

AU - Bentley, A

AU - Bongers, T

AU - Gatheral, T

AU - Felton, T W

AU - Chaudhuri, N

AU - Pearmain, L

PY - 2021/10/31

Y1 - 2021/10/31

N2 - 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.

AB - 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.

KW - COVID-19

KW - Non-invasive ventilation

KW - Oxygen

KW - nIMV

KW - Invasive mechanical ventilation

KW - Ceiling of care

U2 - 10.1016/j.eclinm.2021.101122

DO - 10.1016/j.eclinm.2021.101122

M3 - Article

C2 - 34514360

SN - 2589-5370

VL - 40

SP - 1

EP - 8

JO - EClinicalMedicine

JF - EClinicalMedicine

M1 - 101122

ER -

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

Abstract

Bibliographical note

Keywords

UN SDGs

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Cite this