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; Paul Whittemore; M. Gaddah; K. Kavuri; A. Haley; Paul Denny; C. Withers; R. C. Robey; C. Logue; N. Dahanayake; D Siaw Hui Min; J. Coles; M. S. Deshmukh; S. Ritchie; M. Malik; Hany Abdelaal; K. Sivabalah; M. D. Hartshorne; D. Gopikrishna; A. Ashish; E. Nuttall; Andrew Bentley; T. Bongers; Andrew Bentley; T. Bongers; T. Gatheral; Timothy Felton; Nazia Chaudhuri; Laurence 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, Paul Whittemore, M. Gaddah, K. Kavuri, A. Haley, Paul Denny, C. Withers, R. C. Robey, C. Logue, N. Dahanayake, D Siaw Hui Min, J. Coles, M. S. Deshmukh, S. Ritchie, M. Malik, Hany AbdelaalK. Sivabalah, M. D. Hartshorne, D. Gopikrishna, A. Ashish, E. Nuttall, Andrew Bentley, T. Bongers, Andrew Bentley, T. Bongers, T. Gatheral, Timothy Felton, Nazia Chaudhuri, Laurence Pearmain

Research output: Contribution to journal › Article › peer-review

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.

Original language	English
Article number	101122
Number of pages	1
Journal	EClinicalMedicine
Volume	40
Early online date	8 Sep 2021
DOIs	https://doi.org/10.1016/j.eclinm.2021.101122
Publication status	Published - 1 Oct 2021

Keywords

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

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10.1016/j.eclinm.2021.101122

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., Hui Min, D. S., 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, [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 = "BackgroundContinuous 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.MethodsThis 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.FindingsSeven 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.InterpretationNo 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.",

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

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

note = "Funding Information: The authors would like to acknowledge the NWCORR for providing the platform enabling this collaboration. Additionally, we would like to thank the staff in all study hospitals for their dedication and care towards our patients. Finally, we would like to take the opportunity to remember our patients included in this work, many of whom are sadly no longer with us. Funding Information: L Pearmain is supported by the MRC (MR/R00191X/1). TW Felton is supported by the NIHR Manchester Biomedical Research Centre. Publisher Copyright: {\textcopyright} 2021 The Authors",

year = "2021",

month = oct,

day = "1",

doi = "10.1016/j.eclinm.2021.101122",

language = "English",

volume = "40",

journal = "EClinicalMedicine",

issn = "2589-5370",

publisher = "The Lancet",

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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, Hui Min, DS, Coles, J, Deshmukh, MS, Ritchie, S, Malik, M, Abdelaal, H, Sivabalah, K, Hartshorne, MD, Gopikrishna, D, Ashish, A, Nuttall, E, Bentley, A, Bongers, T, Bentley, A, Bongers, T, Gatheral, T, Felton, T , 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. 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: a multi-centre cohort evaluation

AU - Bradley, P.

AU - Wilson, J.

AU - Taylor, R.

AU - Nixon, J.

AU - Redfern, J.

AU - Whittemore, Paul

AU - Gaddah, M.

AU - Kavuri, K.

AU - Haley, A.

AU - Denny, Paul

AU - Withers, C.

AU - Robey, R. C.

AU - Logue, C.

AU - Dahanayake, N.

AU - Hui Min, D Siaw

AU - Coles, J.

AU - Deshmukh, M. S.

AU - Ritchie, S.

AU - Malik, M.

AU - Abdelaal, Hany

AU - Sivabalah, K.

AU - Hartshorne, M. D.

AU - Gopikrishna, D.

AU - Ashish, A.

AU - Nuttall, E.

AU - Bentley, Andrew

AU - Bongers, T.

AU - Bentley, Andrew

AU - Bongers, T.

AU - Gatheral, T.

AU - Felton, Timothy

AU - Chaudhuri, Nazia

AU - Pearmain, Laurence

N1 - Funding Information: The authors would like to acknowledge the NWCORR for providing the platform enabling this collaboration. Additionally, we would like to thank the staff in all study hospitals for their dedication and care towards our patients. Finally, we would like to take the opportunity to remember our patients included in this work, many of whom are sadly no longer with us. Funding Information: L Pearmain is supported by the MRC (MR/R00191X/1). TW Felton is supported by the NIHR Manchester Biomedical Research Centre. Publisher Copyright: © 2021 The Authors

PY - 2021/10/1

Y1 - 2021/10/1

N2 - BackgroundContinuous 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.MethodsThis 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.FindingsSeven 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.InterpretationNo 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.

AB - BackgroundContinuous 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.MethodsThis 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.FindingsSeven 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.InterpretationNo 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.

KW - COVID-19

KW - Ceiling of care

KW - Invasive mechanical ventilation

KW - Non-invasive ventilation

KW - Oxygen

KW - nIMV

U2 - 10.1016/j.eclinm.2021.101122

DO - 10.1016/j.eclinm.2021.101122

M3 - Article

C2 - 34514360

AN - SCOPUS:85122686378

VL - 40

JO - EClinicalMedicine

JF - EClinicalMedicine

SN - 2589-5370

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

Keywords

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