Variation in Use of High-Flow Nasal Cannula and Noninvasive Ventilation Among Patients With COVID-19

Michael A. Garcia, Shelsey W. Johnson, Emily K. Sisson, Christopher R. Sheldrick, Vishakha K. Kumar, Karen Boman, Scott Bolesta, Vikas Bansal, Marija Bogojevic, J. P. Domecq, Amos Lal, Smith Heavner, Sreekanth R. Cheruku, Donna Lee, Harry L. Anderson, Joshua L. Denson, Ognjen Gajic, Rahul Kashyap, Allan J. Walkey

Research output: Contribution to journalArticlepeer-review


BACKGROUND: The use of high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) for hypoxemic respiratory failure secondary to COVID-19 are recommended by critical-care guidelines; however, apprehension about viral particle aerosolization and patient self-inflicted lung injury may have limited use. We aimed to describe hospital variation in the use and clinical outcomes of HFNC and NIV for the management of COVID-19. METHODS: This was a retrospective observational study of adults hospitalized with COVID-19 who received supplemental oxygen between February 15, 2020, and April 12, 2021, across 102 international and United States hospitals by using the COVID-19 Registry. Associations of HFNC and NIV use with clinical outcomes were evaluated by using multivariable adjusted hierarchical random-effects logistic regression models. Hospital variation was characterized by using intraclass correlation and the median odds ratio. RESULTS: Among 13,454 adults with COVID-19 who received supplemental oxygen, 8,143 (60%) received nasal cannula/face mask only, 2,859 (21%) received HFNC, 878 (7%) received NIV, 1,574 (12%) received both HFNC and NIV, with 3,640 subjects (27%) progressing to invasive ventilation. The hospital of admission contributed to 24% of the risk-adjusted variation in HFNC and 30% of the risk-adjusted variation in NIV. The median odds ratio for hospital variation of HFNC was 2.6 (95% CI 1.4–4.9) and of NIV was 3.1 (95% CI 1.2-8.1). Among 5,311 subjects who received HFNC and/or NIV, 2,772 (52%) did not receive invasive ventilation and survived to hospital discharge. Hospital-level use of HFNC or NIV were not associated with the rates of invasive ventilation or mortality. CONCLUSIONS: Hospital variation in the use of HFNC and NIV for acute respiratory failure secondary to COVID-19 was great but was not associated with intubation or mortality. The wide variation and relatively low use of HFNC/NIV observed within our study signaled that implementation of increased HFNC/ NIV use in patients with COVID-19 will require changes to current care delivery practices. ( registration NCT04323787.).

Original languageEnglish (US)
Pages (from-to)929-938
Number of pages10
JournalRespiratory care
Issue number8
StatePublished - Aug 2022


  • COVID-19
  • SARS-CoV-2
  • high-flow nasal cannula
  • nonin-vasive ventilation
  • viruses

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine
  • Critical Care and Intensive Care Medicine


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