Initial strategy of CPAP, or of high-flow nasal oxygen
Control
Conventional oxygen therapy
Population
1273 patients with acute hypoxaemic respiratory failure due to COVID-19, mean age 57.4, 66% male
Follow-up
30 days
Primary endpoint
Composite of tracheal intubation or mortality within 30 days
Result
Tracheal intubation or death within 30 days occurred in 137 of 377 (36.3%) with CPAP versus 158 of 356 (44.4%) with conventional oxygen — absolute difference -8 percentage points (95% CI -15 to -1, p=0.03). High-flow nasal oxygen gave 44.3%, not significantly different from conventional oxygen. Crossover between interventions occurred in 17.1% overall, and the trial stopped early.
Secondary endpoints
Intubation alone, mortality alone, length of stay
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.
The trial authors, in the published abstract
How it has aged
A rare trial where non-invasive ventilation beat high-flow oxygen, reversing the usual finding of FLORALI and Hernandez 2016. COVID-19 pneumonitis may simply be more recruitable than other causes of hypoxaemic failure. The authors flag early termination and crossover themselves, and SOHO-COVID separately found nothing for high-flow oxygen.
Publications
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
Perkins GD, Ji C, Connolly BA, et al. 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. JAMA 2022 Feb 8;327(6):546-558.
CPAP reduced the composite of intubation or death versus conventional oxygen
High-flow nasal oxygen showed no significant benefit
Stopped early with substantial crossover between groups