Effect of Noninvasive Respiratory Strategies on Intubation or Mortality Among Patients With Acute Hypoxemic Respiratory Failure and COVID-19: The RECOVERY-RS Randomized Clinical Trial.

Importance: Continuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) have been recommended for acute hypoxemic respiratory failure in patients with COVID-19. Uncertainty exists regarding the effectiveness and safety of these noninvasive respiratory strategies. Objective: To determine whether either CPAP or HFNO, compared with conventional oxygen therapy, improves clinical outcomes in hospitalized patients with COVID-19-related acute hypoxemic respiratory failure. Design, Setting, and Participants: A parallel group, adaptive, randomized clinical trial of 1273 hospitalized adults with COVID-19-related acute hypoxemic respiratory failure. The trial was conducted between April 6, 2020, and May 3, 2021, across 48 acute care hospitals in the UK and Jersey. Final follow-up occurred on June 20, 2021. Interventions: Adult patients were randomized to receive CPAP (n = 380), HFNO (n = 418), or conventional oxygen therapy (n = 475). Main Outcomes and Measures: The primary outcome was a composite of tracheal intubation or mortality within 30 days. Results: The trial was stopped prematurely due to declining COVID-19 case numbers in the UK and the end of the funded recruitment period. Of the 1273 randomized patients (mean age, 57.4 [95% CI, 56.7 to 58.1] years; 66% male; 65% White race), primary outcome data were available for 1260. Crossover between interventions occurred in 17.1% of participants (15.3% in the CPAP group, 11.5% in the HFNO group, and 23.6% in the conventional oxygen therapy group). The requirement for tracheal intubation or mortality within 30 days was significantly lower with CPAP (36.3%; 137 of 377 participants) vs conventional oxygen therapy (44.4%; 158 of 356 participants) (absolute difference, -8% [95% CI, -15% to -1%], P = .03), but was not significantly different with HFNO (44.3%; 184 of 415 participants) vs conventional oxygen therapy (45.1%; 166 of 368 participants) (absolute difference, -1% [95% CI, -8% to 6%], P = .83). Adverse events occurred in 34.2% (130/380) of participants in the CPAP group, 20.6% (86/418) in the HFNO group, and 13.9% (66/475) in the conventional oxygen therapy group. Conclusions and Relevance: Among patients with acute hypoxemic respiratory failure due to COVID-19, an initial strategy of CPAP significantly reduced the risk of tracheal intubation or mortality compared with conventional oxygen therapy, but there was no significant difference between an initial strategy of HFNO compared with conventional oxygen therapy. The study may have been underpowered for the comparison of HFNO vs conventional oxygen therapy, and early study termination and crossover among the groups should be considered when interpreting the findings. Trial Registration: isrctn.org Identifier: ISRCTN16912075.

Adherence to National Asthma Guidelines in the Acute Care Setting: A Retrospective Cohort Study.

BACKGROUND: Peak flow is a crucial but simple test used to categorize the severity of an episode of an acute exacerbation of asthma. It should be regularly done in all the patients who present with asthma acute exacerbation in the emergency department. The British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN) guidelines stipulate peak flow use as one of the main tools to categorize acute asthma into moderate, severe, and life-threatening asthma. The BTS and SIGN guidelines also state peak flow is to be utilized in monitoring the disease and to guide in treating patients with acute asthma. METHODS AND MATERIALS: This study aims to identify the adherence to BTS/SIGN guidelines around the use of peak expiratory flow rate (PEFR) in assessing the severity of patients presenting with acute exacerbation of asthma in a district general hospital. The retrospective cohort study involved collating data between October 2022 and February 2023 from our hospital electronic system. The data collected about the use of PEFR and whether the patients were being classified by severity in presentation following this was compared to the BTS/SIGN 158 asthma guidelines. Following this, the data analysis was done using IBM SPSS Statistics for Windows, Version 21.0 (Released 2012; IBM Corp., Armonk, New York, United States). RESULTS: Data from 92 patients were collated. PEFR was recorded for 29.3% (n=27) of patients and acute exacerbation of asthma severity was documented in merely 17.4% (n=16) patients. CONCLUSION: The results indicate a significant proportion of the patient cohort analyzed did not have peak flow readings, there is clear room for improvement, and further intervention is needed in order for the department to adhere to the gold standard guidelines (i.e., BTS/SIGN 158), and thus improve the management and monitoring of acute asthma exacerbations. Future directions can include departmental education, posters as a reminder, and prompts on the electronic system used to alert users to check PEFR when a diagnosis of acute asthma exacerbation is documented.