Xu Jiqian, Yang Xiaobo, Huang Chaolin, Zou Xiaojing, Zhou Ting, Pan Shangwen, Yang Luyu, Wu Yongran, Ouyang Yaqi, Wang Yaxin, Xu Dan, Zhao Xin, Shu Huaqing, Jiang Yongxiang, Xiong Wei, Ren Lehao, Liu Hong, Yuan Yin, Qi Hong, Fu Shouzhi, Chen Dechang, Zhang Dingyu, Yuan Shiying, Shang You
Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
Research Center for Translational Medicine, Jinyintan Hospital, Wuhan, China.
Front Med (Lausanne). 2020 Dec 8;7:607821. doi: 10.3389/fmed.2020.607821. eCollection 2020.
High-flow nasal cannula (HFNC) has been recommended as a suitable choice for the management of coronavirus disease 2019 (COVID-19) patients with acute hypoxemic respiratory failure before mechanical ventilation (MV); however, delaying MV with HFNC therapy is still a dilemma between the technique and clinical management during the ongoing pandemic. Retrospective analysis of COVID-19 patients treated with HFNC therapy from four hospitals of Wuhan, China. Demographic information and clinical variables before, at, and shortly after HFNC initiation were collected and analyzed. A risk-stratification model of HFNC failure (the need for MV) was developed with the 324 patients of Jin Yin-tan Hospital and validated its accuracy with 69 patients of other hospitals. Among the training cohort, the median duration of HFNC therapy was 6 (range, 3-11), and 147 experienced HFNC failure within 7 days of HFNC initiation. Early predictors of HFNC failure on the basis of a multivariate regression analysis included age older than 60 years [odds ratio (OR), 1.93; 95% confidence interval (CI), 1.08-3.44; = 0.027; 2 points], respiratory rate-oxygenation index (ROX) <5.31 (OR, 5.22; 95% CI, 2.96-9.20; < 0.001; 5 points) within the first 4 h of HFNC initiation, platelets < 125 × 10/L (OR, 3.04; 95% CI, 1.46-6.35; = 0.003; 3 points), and interleukin 6 (IL-6) >7.0 pg/mL (OR, 3.34; 95% CI, 1.79-6.23; < 0.001; 3 points) at HFNC initiation. A weighted risk-stratification model of these predictors showed sensitivity of 80.3%, specificity of 71.2% and a better predictive ability than ROX index alone [area under the curve (AUC) = 0.807 vs. 0.779, < 0.001]. Six points were used as a cutoff value for the risk of HFNC failure stratification. The HFNC success probability of patients in low-risk group (84.2%) was 9.84 times that in the high-risk group (34.8%). In the subsequent validation cohort, the AUC of the model was 0.815 (0.71-0.92). Aged patients with lower ROX index, thrombocytopenia, and elevated IL-6 values are at increased risk of HFNC failure. The risk-stratification models accurately predicted the HFNC failure and early stratified COVID-19 patients with HFNC therapy into relevant risk categories.
高流量鼻导管吸氧（HFNC）已被推荐为2019冠状病毒病（COVID-19）急性低氧性呼吸衰竭患者在机械通气（MV）前的一种合适治疗选择；然而，在当前疫情期间，使用HFNC治疗延迟MV在技术和临床管理方面仍是一个两难问题。对来自中国武汉四家医院接受HFNC治疗的COVID-19患者进行回顾性分析。收集并分析了HFNC开始前、开始时及开始后不久的人口统计学信息和临床变量。利用金银潭医院的324例患者建立了HFNC失败（需要MV）的风险分层模型，并用其他医院的69例患者验证了其准确性。在训练队列中，HFNC治疗的中位持续时间为6天（范围3 - 11天），147例患者在HFNC开始后7天内出现HFNC失败。基于多因素回归分析的HFNC失败早期预测因素包括年龄大于60岁[比值比（OR），1.93；95%置信区间（CI），1.08 - 3.44；P = 0.027；2分]、HFNC开始后4小时内呼吸频率 - 氧合指数（ROX）<5.31（OR，5.22；95% CI，2.96 - 9.20；P < 0.001；5分）、血小板<125×10⁹/L（OR，3.04；95% CI，1.46 - 6.35；P = 0.003；3分）以及HFNC开始时白细胞介素6（IL - 6）>7.0 pg/mL（OR，3.34；95% CI，1.79 - 6.23；P < 0.001；3分）。这些预测因素的加权风险分层模型显示敏感性为80.3%，特异性为71.2%，且预测能力优于单独的ROX指数[曲线下面积（AUC）= 0.807对0.779；P < 0.001]。六点被用作HFNC失败分层风险的截断值。低风险组患者HFNC成功概率（84.2%）是高风险组患者（34.8%）的9.84倍。在随后的验证队列中，该模型的AUC为0.815（0.71 - 0.92）。年龄较大、ROX指数较低、血小板减少和IL - 6值升高的患者HFNC失败风险增加。该风险分层模型准确预测了HFNC失败，并将接受HFNC治疗的COVID-19患者早期分层为相关风险类别。
