COVID-19 has developed worldwide since 2019, resulting in the most serious of cases in the development of hypoxemic respiratory failure. In light of the rapid worsening of those severe patients at the beginning of the epidemic in our country, to reduce possible subsequent aerosolization of the SARS-CoV-2 virus, early intubation was proposed as a first step [1]. Subsequently, it turned out that some patients were finally able to benefit from high-flow nasal cannula (HFNC) alone or with prone position and thus avoid intubation and its potential complications [2]. The benefit of HFNC is based on the reliability of oxygen distribution, on its good tolerance and on the reduction of the rate of intubation [2].
COVID-19 patients regularly require interhospital transport for diagnostic or therapeutic purposes, particularly due to intensive care unit (ICU) overcrowding. The question of transport for severe COVID-19 patients under HFNC arose. Several major limitations are important to take into account. Firstly, the equipment used in our country to provide HFNC is not autonomous on battery and requires a continuous electric current. So, during the critical transport phases—leaving the room, arriving in the ambulance, leaving the ambulance, movement to the receiving department—the patient can no longer benefit from a high flow of humidified and reheated oxygen. Helicopter transport is not feasible. Secondly, the transport of highly infectious COVID-19 patients under HFNC or high-flow oxygen mask (HFOM) carries an additional risk of virus aerosolization and transmission to the transport team in enclosed spaces like hallways, elevators or ambulances, even if a simple surgical mask can control dispersion of aerosols or droplets [[3], [4], [5]].
While some transports under HFNC went well, several adverse events lead us to be cautious with patients who have to be intubated urgently.
A few points are important to remember:
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We recommend performing a well-supported 15-min broadband weaning test before allowing this transport. Physicians will check for signs of respiratory failure for 15 min after switching from an HFNC to a HFOM.
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We suggest isolation protection efforts with patients on HFNC wearing a mask over the nasal interface or a contained respiratory hood.
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We propose determining the ROX index to predict high-flow nasal cannula (HFNC) failure/need for intubation [6,7].
When these criteria are not met, we have repeatedly suggested using Boussignac CPAP (Vygon, Ecouen, France) as a reliable alternative approach. This is a simple continuous positive airway pressure (CPAP) device, made up of an oronasal mask and a valve connected to an oxygen source and requiring no electric power source. In order to protect the environment and the medical staff from any contamination from the patient's airway, a heat and moisture exchanger was added, acting as a “microbiological barrier” between the oronasal mask and the CPAP valve. We have shown that this device is safe [8].
Disclosure statement
The authors report no conflict of interest.
Data availability
There is no data set with this paper, this position paper was done without patient involvement.
Data deposition
Not applicable.
Funding
This work wasn't supported by any fund.
References
- 1.World Health Organisation Clinical management of COVID-19. 2020. https://www.who.int/publications-detail-redirect/clinical-management-of-covid-19 Available at.
- 2.Demoule A., Vieillard Baron A., Darmon M., Beurton A., Géri G., Voiriot G., et al. High-flow nasal cannula in critically III patients with severe COVID-19. Am J Respir Crit. 2020;202:1039–1042. doi: 10.1164/rccm.202005-2007LE. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Li J., Fink J.B., Ehrmann S. High-flow nasal cannula for COVID-19 patients: risk of bio-aerosol dispersion. Eur Respir J. 2020;56 doi: 10.1183/13993003.03136-2020. [In press] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Leonard S., Atwood C.W., Walsh B.K., DeBellis R.J., Dungan G.C., Strasser W., et al. Preliminary findings on control of dispersion of aerosols and droplets during high-velocity nasal insufflation therapy using a simple surgical mask: implications for the high-flow nasal cannula. Chest. 2020;158:1046–1049. doi: 10.1016/j.chest.2020.03.043. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.World Health Organisation Infection prevention during transfer and transport of patients with suspected COVID-19 requiring hospital care. 2020. https://apps.who.int/iris/bitstream/handle/10665/331917/COVID-19-infection-prevention-during-transfer-and-transport-eng.pdf?sequence=1&isAllowed=y Available at.
- 6.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. 2018;199:1368–1376. doi: 10.1164/rccm.201803-0589OC. [DOI] [PubMed] [Google Scholar]
- 7.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;35:200–205. doi: 10.1016/j.jcrc.2016.05.022. [DOI] [PubMed] [Google Scholar]
- 8.Carteaux G., Pons M., Morin F., Tuffet S., Lesimple A., Badat B., et al. Continuous positive airway pressure for respiratory support during COVID-19 pandemic: a frugal approach from bench to bedside. Ann Intensive Care. 2021;11(1):38. doi: 10.1186/s13613-021-00828-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
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Data Availability Statement
There is no data set with this paper, this position paper was done without patient involvement.