The Impact of High-Flow Nasal Cannula Use on Patient Mortality and the Availability of Mechanical Ventilators in COVID-19

Ann Am Thorac Soc. 2021 Apr;18(4):623-631. doi: 10.1513/AnnalsATS.202007-803OC.


Rationale: How to provide advanced respiratory support for coronavirus disease (COVID-19) to maximize population-level survival while optimizing mechanical ventilator access is unknown.Objectives: To evaluate the use of high-flow nasal cannula for COVID-19 on population-level mortality and ventilator availability.Methods: We constructed dynamical (deterministic) simulation models of high-flow nasal cannula and mechanical ventilation use for COVID-19 in the United States. Model parameters were estimated through consensus based on published literature, local data, and experience. We had the following two outcomes: 1) cumulative number of deaths and 2) days without any available ventilators. We assessed the impact of various policies for the use of high-flow nasal cannula (with or without "early intubation") versus a scenario in which high-flow nasal cannula was unavailable.Results: The policy associated with the fewest deaths and the least time without available ventilators combined the use of high-flow nasal cannula for patients not urgently needing ventilators with the use of early mechanical ventilation for these patients when at least 10% of ventilator supply was not in use. At the national level, this strategy resulted in 10,000-40,000 fewer deaths than if high-flow nasal cannula were not available. In addition, with moderate national ventilator capacity (30,000-45,000 ventilators), this strategy led to up to 25 (11.8%) fewer days without available ventilators. For a 250-bed hospital with 100 mechanical ventilators, the availability of 13, 20, or 33 high-flow nasal cannulas prevented 81, 102, and 130 deaths, respectively.Conclusions: The use of high-flow nasal cannula coupled with early mechanical ventilation when supply is sufficient results in fewer deaths and greater ventilator availability.

Keywords: COVID-19; high-flow nasal cannula; mechanical ventilation; simulation.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • COVID-19 / complications
  • COVID-19 / mortality*
  • COVID-19 / therapy*
  • Cannula*
  • Computer Simulation
  • Critical Care
  • Female
  • Hospital Mortality
  • Hospitalization
  • Humans
  • Male
  • Middle Aged
  • Oxygen Inhalation Therapy / instrumentation*
  • Oxygen Inhalation Therapy / statistics & numerical data
  • Procedures and Techniques Utilization
  • Respiration, Artificial / instrumentation*
  • Respiration, Artificial / statistics & numerical data
  • Survival Rate
  • Treatment Outcome
  • United States
  • Ventilators, Mechanical
  • Young Adult