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Abstract

Background:

The new global definition of nonintubated subjects with ARDS can be applied to patients receiving high-flow nasal cannula (HFNC), but stratification with P_aO₂/F_IO₂ has not been validated. We aimed to investigate the differences in oxygenation assessment between HFNC and CPAP for predicting outcomes.

Methods:

We performed a post hoc analysis of a multi-center randomized controlled trial conducted in Japan, focusing on oxygenation assessments in subjects receiving HFNC or CPAP. Subjects with P_aO₂/F_IO₂ < 300 on CPAP at 5 cm H₂O were assigned to receive either HFNC or CPAP. Subjects were stratified into mild (P_aO₂/F_IO₂ ≥ 200 but <300), moderate (P_aO₂/F_IO₂ ≥ 100 but < 200), or severe (P_aO₂/F_IO₂ < 100) hypoxemia categories based on oxygenation levels during CPAP at 5 cm H₂O. The primary outcome was treatment failure (intubation or in-hospital death). Discriminative performance for treatment failure was evaluated using the area under the receiver operating characteristic curve (AUROC) for each device.

Results:

Of the 85 subjects analyzed, 31, 48, and 6 were classified as having mild, moderate, and severe hypoxemia, respectively. Treatment failure occurred more frequently in subjects with moderate and severe hypoxemia than in those with mild hypoxemia (mild 1/31 [3.2%], moderate: 12/48 [25.0%], severe: 3/6 [50.0%], P = .004). Compared with 1 of 38 subjects (2.6%) treated with CPAP, 21 of 47 subjects (44.7%) with HFNC experienced worsened oxygenation even after 30 min of treatment (P < .001). Subjects with HFNC had a lower AUROC of P_aO₂/F_IO₂ for treatment failure (0.66, 95% CI 0.54–0.79) than those with CPAP (0.82, 95% CI 0.74–0.90, P = .041).

Conclusions:

P_aO₂/F_IO₂-based stratification may help predict treatment failure in patients with nonintubated subjects with ARDS. However, a thorough oxygenation assessment is necessary because of the variability introduced by different respiratory support devices. CPAP might be superior to HFNC when predicting treatment failure.

Keywords

acute respiratory distress syndrome continuous positive airway pressure high-flow nasal cannula hypoxemic respiratory failure oxygenation severity

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