High-flow nasal cannula for Acute Respiratory Distress Syndrome (ARDS) due to COVID-19


Background: High-flow nasal cannula oxygen therapy (HFNC) has been shown to be a useful therapy in the treatment of patients with Acute Respiratory Distress Syndrome (ARDS), but its efficacy is still unknown in patients with COVID-19. Our objective is to describe its utility as therapy for the treatment of ARDS caused by SARS-CoV-2. 
Methods: A retrospective, observational study was performed at a single centre, evaluating patients with ARDS secondary to COVID-19 treated with HFNC. The main outcome was the intubation rate at day 30, which defined failure of therapy. We also analysed the role of the ROX index to predict the need for intubation.
Results: In the study period, 196 patients with bilateral pneumonia were admitted to our pulmonology unit, 40 of whom were treated with HFNC due to the presence of ARDS. The intubation rate at day 30 was 52.5%, and overall mortality was 22.5%. After initiating HFNC, the SpO2/FiO2 ratio was significantly better in the group that did not require intubation (113.4±6.6 vs 93.7±6.7, p=0.020), as was the ROX index (5.0±1.6 vs 4.0±1.0, p=0.018). A ROX index less than 4.94 measured 2 to 6 h after the start of therapy was associated with increased risk of intubation (HR 4.03 [95% CI 1.18 – 13.7]; p=0.026).
Conclusion: High-flow therapy is a useful treatment in ARDS in order to avoid intubation or as a bridge therapy, and no increased mortality was observed secondary to the delay in intubation. After initiating HFNC, a ROX index below 4.94 predicts the need for intubation.



PlumX Metrics


Download data is not yet available.


Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382:727–33. DOI: https://doi.org/10.1056/NEJMoa2001017

Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA 2020;323:1061. DOI: https://doi.org/10.1001/jama.2020.1585

Frat J-P, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015;372:2185–96. DOI: https://doi.org/10.1056/NEJMoa1503326

Parke RL, Eccleston ML, McGuinness SP. The Effects of flow on airway pressure during nasal high-flow oxygen therapy. Respir Care 2011;56:1151–5. DOI: https://doi.org/10.4187/respcare.01106

Rochwerg B, Granton D, Wang DX, Helviz Y, Einav S, Frat JP, et al. High flow nasal cannula compared with conventional oxygen therapy for acute hypoxemic respiratory failure: a systematic review and meta-analysis. Intensive Care Med 2019;45:563–72. DOI: https://doi.org/10.1007/s00134-019-05658-2

ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, et al. Acute respiratory distress syndrome: the Berlin definition. JAMA 2012;307:2526–33.

Roca O, Messika J, Caralt B, García-de-Acilu M, Sztrymf B, Ricard J-D, et al. Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: The utility of the ROX index. J Crit Care 2016;35:200–5. DOI: https://doi.org/10.1016/j.jcrc.2016.05.022

Kang BJ, Koh Y, Lim C-M, Huh JW, Baek S, Han M, et al. Failure of high-flow nasal cannula therapy may delay intubation and increase mortality. Intensive Care Med 2015;41:623–32. DOI: https://doi.org/10.1007/s00134-015-3693-5

Messika J, Ahmed K Ben, Gaudry S, Miguel-Montanes R, Rafat C, Sztrymf B, et al. Use of high-flow nasal cannula oxygen therapy in subjects with ARDS: A 1-year observational study. Respir Care 2015;60:162-9. DOI: https://doi.org/10.4187/respcare.03423

Roca O, Caralt B, Messika J, Samper M, Sztrymf B, Hernández G, et al. An index combining respiratory rate and oxygenation to predict outcome of nasal high-flow therapy. Am J Respir Crit Care Med 2019;199:1368–76. DOI: https://doi.org/10.1164/rccm.201803-0589OC

Roussos C, Koutsoukou A. Respiratory failure. Eur Respir J 2003;47:s3-14. DOI: https://doi.org/10.1183/09031936.03.00038503

Nishimura M. High-flow nasal cannula oxygen therapy devices. Respir Care 2019;64:735-42. DOI: https://doi.org/10.4187/respcare.06718

Wang K, Zhao W, Li J, Shu W, Duan J. The experience of high-flow nasal cannula in hospitalized patients with 2019 novel coronavirus-infected pneumonia in two hospitals of Chongqing, China. Ann Intensive Care 2020;10:37. DOI: https://doi.org/10.1186/s13613-020-00653-z

Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med 2020;8:475-81. DOI: https://doi.org/10.1016/S2213-2600(20)30079-5

Cheung JCH, Ho LT, Cheng JV, Cham EYK, Lam KN. Staff safety during emergency airway management for COVID-19 in Hong Kong. Lancet Respir Med. 2020;8:e19. DOI: https://doi.org/10.1016/S2213-2600(20)30084-9

Raboud J, Shigayeva A, McGeer A, Bontovics E, Chapman M, Gravel D, et al. Risk factors for SARS Transmission from patients requiring intubation: Amulticentre investigation in Toronto, Canada. PLoS One 2010;5:e10717. DOI: https://doi.org/10.1371/journal.pone.0010717

Li J, Fink JB, Ehrmann S. High-flow nasal cannula for COVID-19 patients: low risk of bio-aerosol dispersion. Eur Respir J 2020;55:2000892. DOI: https://doi.org/10.1183/13993003.00892-2020

Rello J, Pérez M, Roca O, Poulakou G, Souto J, Laborda C, et al. High-flow nasal therapy in adults with severe acute respiratory infection: A cohort study in patients with 2009 influenza A/H1N1v. J Crit Care 2012;27:434–9. DOI: https://doi.org/10.1016/j.jcrc.2012.04.006

Wu C, Chen X, Cai Y, Xia J, Zhou X, Xu S, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med 2020;180:e200994. DOI: https://doi.org/10.1001/jamainternmed.2020.0994

Lim WS, Eerden MM van der, Laing R, Boersma WG, Karalus N, Town GI, et al. Defining community-acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003;58:377–82. DOI: https://doi.org/10.1136/thorax.58.5.377

Original Research Articles
COVID-19, high-flow nasal cannula, acute respiratory distress syndrome, coronavirus
  • Abstract views: 2147

  • PDF: 922
  • HTML: 0
How to Cite
Panadero, C., Abad-Fernández, A., Rio-Ramírez , M. T., Acosta Gutiérrez, C. M., Calderón-Alcalá , M., López-Riolobos, C., Matesanz-López , C., Garcia-Prieto , F., Diaz-Garcia, J. M., Raboso-Moreno, B., Vasquez-Gambasica, Z., Andres-Ruzafa, P., García-Satué , J. L., Calero-Pardo , S., Sagastizabal, B., Bautista, D., Campos, A., Gonzalez, M., Grande, L., Jimenez Fernandez, M., Santiago-Ruiz, J. L., Caravaca Perez, P., & Alcaraz, A. J. (2020). High-flow nasal cannula for Acute Respiratory Distress Syndrome (ARDS) due to COVID-19. Multidisciplinary Respiratory Medicine, 15. https://doi.org/10.4081/mrm.2020.693