The overall mortality rate 4 weeks after hospital admission was 24%, with age, acute kidney injury, and respiratory distress as the associated factors. After adjustment, and taking patients treated with HFNC as reference, patients who underwent NIV had a higher risk of intubation or death at 28days (HR 2.01, 95% CI 1.323.08), while those treated with CPAP did not present differences (HR 0.97, 95% CI 0.631.50) (Table 4). Bivariate analysis was performed by survival status of COVID-19 positive patients to examine differences in the survival and non-survival group using chi-square tests and Welchs t-test. Sci Rep 12, 6527 (2022). In contrast, a randomized study of 110 COVID-19 patients admitted to the ICU found no differences in the 28-day respiratory support-free days (primary outcome) or mortality between helmet NIV and HFNC, but recorded a lower risk of endotracheal intubation with helmet NIV (30%, vs. 51% for HFNC)19. Respir. Sci. The majority of patients (N = 123, 93.9%) received a combination of azithromycin and hydroxychloroquine. Cite this article. 202, 10391042 (2020). Respiratory Department. Major clinical outcomes analyzed at the end of the study period were: hospital and ICU length of stay, MV-related mortality and overall hospital mortality of ICU patients. Clinicaltrials.gov identifier: NCT04668196. JAMA 323, 15451546 (2020). Statistical significance was set at P<0.05. The ICUs employed dedicated respiratory therapists, with extensive training in the care of patients with ARDS. Respir. Keep reading as we explain how. Fifth, we cannot exclude the possibility that NIV implied a more complicated clinical course than HFNC or CPAP. A multivariate logistic regression model was performed to investigate the associations between mortality and clinical and demographic characteristics of COVID-19 positive patients on mechanical ventilation in the ICU. Patel, B. K., Wolfe, K. S., Pohlman, A. S., Hall, J. Early paralysis and prone positioning were achieved with the assistance of a dedicated prone team. ICU specific management and interventions including experimental therapies and hospital as well as ICU length of stay (LOS) are described in Table 3. Patients referred to our center from outside our system included patients to be evaluated for Extracorporeal Membrane Oxygenation (ECMO) and patients who experienced delays in hospital level of care due to travel on cruise lines. No significant differences in the laboratory and inflammatory markers were observed between survivors and non-survivors. Our observed mortality does not suggest a detrimental effect of such treatment. Care Med. Drafting of the manuscript: S.M., A.-E.C. Membership of the author group is listed in the Acknowledgments. Khaled Fernainy, 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. During March 11 to May 18, a total of 1283 COVID-19 positive patients were evaluated in the Emergency Department or ambulatory care centers of AHCFD. Eur. & Pesenti, A. As with all observational studies, it is difficult to ascertain causality with ICU therapies as opposed to an association that existed due to the patients clinical conditions. During the follow-up period, 44 patients (12%) switched to another NIRS treatment: eight (5%) in the HFNC group (treated subsequently with NIV), 28 (21%) in the CPAP group (13 switched to HFNC, and 15 to NIV), and eight (10%) in the NIV group (seven treated with HFNC, and one with CPAP). Abstract Introduction Atrial fibrillation (AF), the most frequent arrhythmia of older patients, associates with serious . The cumulative percentage of patients who had received intubation or who had died by day 28 (primary outcome) was 45.8% in the HFNC group, 36.8% in the CPAP group, and 60.8% in the NIV group (Fig. According to Professor Jenkins, mortality rates have halved as a result of clinical trials that have led to better management of COVID-19 pneumonia and respiratory failure. However, little is known about the physiologic consequences of the volatile anesthetics when used for long periods in patients who are infected with Covid-19. Oxygen therapy for acutely ill medical patients: A clinical practice guideline. Therefore, the poor ICU outcomes and high mortality rate observed during CARDS have raised concerns about the strategies of mechanical ventilation and the success in delivering standard of care measures. J. Official ERS/ATS clinical practice guidelines: Noninvasive ventilation for acute respiratory failure. J. Respir. Methods. Thank you for visiting nature.com. The study took place between . Penn and Barstool Sports first announced an exclusive sports betting and iCasino partnership in early 2020. Based on these high mortality rates, there has been speculation that this disease process is different than typical ARDS, suggesting that standard ARDS mechanical ventilation strategies may not be as effective in reducing lung injury [22]. Our study does not support the previously reported overwhelmingly poor outcomes of mechanically ventilated patients with COVID-19 induced respiratory failure and ARDS. In this multicentre, observational real-life study, we aimed to compare the effects of high-flow oxygen administered via nasal cannula, continuous positive airway pressure, and noninvasive ventilation, initiated outside the intensive care unit, in preventing death or endotracheal intubation at 28days in patients with COVID-19. It isn't clear how long these effects might last. All participating hospitals belong to the National Health System of Catalonia, Spain, and attend a population of around 4.3 million inhabitants. Characteristics of the patients at baseline according to NIRS treatment were described by mean and standard deviation, median and 25th and 75th percentiles (P25 and P75) and by absolute and relative frequencies, and compared using Chi2, Anova and Kruskal Wallis tests. This was an observational study conducted at a single health care system in a confined geographic area thus limiting the generalizability of our results. You are using a browser version with limited support for CSS. Bronconeumol. The primary outcome was treatment failure, defined as endotracheal intubation or death within 28days of NIRS initiation. In mechanically ventilated patients, mortality has ranged from 5097%. & Laghi, F. Noninvasive strategies in COVID-19: Epistemology, randomised trials, guidelines, physiology. The study was conducted from October 2020 to March 2022 in a province in southern Thailand. Categorical fields are displayed as percentages and continuous fields are presented as means or standard deviations (SD) or median and interquartile range. In order to minimize the risks of infection to staff, we applied NIV and CPAP treatments through oronasal or total face non-vented masks attached to single-limb circuits with intentional leak, and placing a low-pressure viral filter preventing exhaled droplet dispersion; in HFNC-treated patients, a surgical mask was put over the nasal prongs8,9. Respir. Tobin, M. J., Jubran, A. In fact, retrospective and prospective case series from China and Italy have provided insight about the clinical course of severely ill patients with CARDS in which it demonstrates that extrapulmonary complications are also a strong contributor for poor outcomes [4, 5]. Reported cardiotoxicity associated with this regimen was mitigated by frequent ECG monitoring and close monitoring of electrolytes. Nasa, P. et al. Another potential aspect that may have contributed to reduce our MV-related mortality and overall mortality is the use of steroids. To obtain 195, 12071215 (2017). Am. As mentioned above, NIV might have better outcomes in a more controlled setting allowing an optimal critical care39. Ventilators can be lifesaving for people with severe respiratory symptoms. J. For full functionality of this site, please enable JavaScript. Thorax 75, 9981000 (2020). Respiratory support in patients with severe COVID-19 in the International Severe Acute Respiratory and Emerging Infection (ISARIC) COVID-19 study: a prospective, multinational,. 10 A person can develop symptoms between 2 to 14 days after contact with the virus. Chest 160, 175186 (2021). Slider with three articles shown per slide. In addition, some COVID-19 patients cannot be considered for invasive ventilation due to their frailty or comorbidities, and others are unwilling to undergo invasive techniques. Recently, the effectiveness of CPAP or HFNC compared with conventional oxygen therapy was assessed in the RECOVERY-RS multicentric randomized clinical trial, in 1,273 COVID-19 patients with HARF who were deemed suitable for tracheal intubation if treatment escalation was required20. PubMed Central All patients with COVID-19 who met criteria for critical care admission from AdventHealth hospitals were transferred and managed at AdventHealth Orlando, a 1368-bed hospital with 170 ICU beds and dedicated inhouse 24/7 intensivist coverage. J. Med. However, in countries where the majority population were non-black (China, Italy, and other countries in Europe), a high mortality rate was also observed. The data used in these figures are considered preliminary, and the results may change with subsequent releases. J. Med. Brochard, L., Slutsky, A. Approximately half of the study population had commercial insurance (67, 51%) followed by Medicare (40, 30.5%), Medicaid (12, 9.2%) and uninsured (12, 9.2%). In the NIV and CPAP groups, if the treatment was not tolerated continuously, a minimal duration of 8h per day, predominantly during the night, was attempted, reaching a mean usage of 22 (4) h/day in NIV and 21 (4) h/day in CPAP (min-P25-median-P75-max 8-22-24-24-24 in both groups). NHCS results provided on COVID-19 hospital use are from UB-04 administrative claims data from March 18, 2020 through September 27, 2022 from 42 hospitals that submitted inpatient data and 43 hospitals that submitted ED data. It's unclear why some, like Geoff Woolf, a 74-year-old who spent 306 days in the hospital, survive. Our study supports several guidelines37,38 that favor HFNC and CPAP over NIV for the treatment of HARF in COVID-19 patients, but to our knowledge no previous data have been published in support of this recommendation. From January to May of 2020, according to the international registry, less than 40 percent of Covid patients died in the first 90 days after ECMO was started. No significant differences in the main outcome were found between HFNC (44%) vs conventional oxygen therapy (45%; absolute difference, 1% [95% CI, 8% to 6%], p=0.83). KEY Points. Higher mortality and intubation rate in COVID-19 patients treated with noninvasive ventilation compared with high-flow oxygen or CPAP. Inflammation and problems with the immune system can also happen. Among the patients with COVID-19 CAP, mortalities, mechanical ventilators, ICU admissions, ICU stay, and hospital costs . LHer, E. et al. Frat, J. P. et al. Additional adjustment for D-dimer, respiratory rate, Charlson index, or treatment with systemic corticosteroids produced very similar results (Table S10). Prone Positioning techniques were consistent with the PROSEVA trial recommendations [17]. Mauri, T. et al. Vaccinated COVID patients fare better on mechanical ventilation, data show A new study in JAMA Network Open suggests vaccinated COVID-19 patients intubated for mechanical ventilation had a higher survival rate than unvaccinated or partially vaccinated patients. Eur. J. Feasibility and clinical impact of out-of-ICU noninvasive respiratory support in patients with COVID-19-related pneumonia. https://doi.org/10.1038/s41598-022-10475-7, DOI: https://doi.org/10.1038/s41598-022-10475-7. All analyses were performed using StataCorp. The analyses excluding patients with missing PaO2/FIO2 or receiving NIRS as ceiling of treatment showed similar associations to those observed in the main analysis (Tables S6 and S7, respectively). MiNK Therapeutics Announces 77% Survival Rate in Intubated Patients with COVID-19 Respiratory Failure Treated with AgenT-797 PRESS RELEASE GlobeNewswire Nov. 12, 2021, 07:00 AM N. Engl. 55, 2000632 (2020). In a May 26 study in the journal Critical Care Medicine, Martin and a group of colleagues found that 35.7 percent of covid-19 patients who required ventilators died a significant percentage. Differences were also found in the NIRS treatments applied according to the date of admission: HFNC was the most frequent treatment early in the period (before 23 March), while CPAP was the most frequent choice in the second and the third periods (Table 1, p=0.008). Our study describes the clinical characteristics and outcomes of patients with severe COVID-19 admitted to ICU in the largest health care system in the state of Florida, United States. Obviously, reaching a definitive conclusion on this point will require further studies with better phenotypic characterization of patients, and considering additional factors implicated in the response to therapies such as the interface used or the monitoring of the inspiratory effort. In United States, population dense areas such as New York City, Seattle and Los Angeles have had the highest rates of infection resulting in significant overload to hospitals and ICU systems [1, 6, 7]. Early reports out of Wuhan, China, and Italy cemented the impression that the vast . 56, 2001935 (2020). Am. Lower positive end expiratory pressure (PEEP) averages were observed in survivors [9.2 cm H2O (7.710.4)] vs non-survivors [10 (9.112.9] p = 0.004]. Secondary outcomes were 28-day mortality, endotracheal intubation at day 28, in-hospital mortality, and duration of hospital stay. By submitting a comment you agree to abide by our Terms and Community Guidelines. Google Scholar. 4h ago. JAMA 327, 546558 (2022). Renal replacement therapy was required in 24 (18%), out of which 15 patients (57.7%) expired. PR(AG)265/2020). Common comorbidities were hypertension (84; 64.1%), and diabetes (54; 41.2%). D-dimer levels and respiratory rate at baseline were also significantly associated with treatment, but since they had missing values for 82 and 41 patients respectively, these variables were only included in a sensitivity analysis. In the treatment of HARF with CPAP or NIV the interface via which these treatments are applied should be considered, since better outcomes have been reported with a helmet interface than with face masks in non-COVID patients6,35 , possibly due to a greater tolerance of the helmet and a more effective delivery of PEEP36. Background. People who had severe illness with COVID-19 might experience organ damage affecting the heart, kidneys, skin and brain. Outcomes of COVID-19 patients intubated after failure of non-invasive ventilation: a multicenter observational study, Early extubation with immediate non-invasive ventilation versus standard weaning in intubated patients for coronavirus disease 2019: a retrospective multicenter study, Patient characteristics and outcomes associated with adherence to the low PEEP/FIO2 table for acute respiratory distress syndrome. Finally, additional unmeasured factors might have played a significant role in survival. J. Biomed. B. Most patients were supported with mechanical ventilation. 26, 5965 (2020). For initial laboratory testing and clinical studies for which not all patients had values, percentages of total patients with completed tests are shown. When COVID-19 leads to ARDS, a ventilator is needed to help the patient breathe. With an expected frequency of 50% for intubation or death in patients with HARF and treated by NIRS28, 300 patients were needed in order to detect a significant difference greater than 20% between the types of NIRS evaluated in the present study, with an alpha risk of 0.05 and a statistical power of 80%. Google Scholar. Crit. Opin. Study conception and design: S.M., J.S., J.F., J.G.-A. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. The 28-days Kaplan Meier curves from: (a) day starting NIRS to death or intubation; (b) day starting NIRS to intubation; and (c) day starting NIRS to death. A covid-19 patient is attached to a ventilator in the emergency room at St. Joseph's Hospital in Yonkers, N.Y., in April. First, NIV has been reported to produce overdistension, compounded by the respiratory effort itself30, which could result in ventilation-induced lung injury due to the excessive increases in tidal volumes28,31. We recruited 367 consecutive patients aged18years who were treated with HFNC (155, 42.2%), CPAP (133, 36.2%) or NIV (79, 21.5%). The decision regarding the choice of treatment was taken by the pulmonologist in charge of the patients care, with HFNC usually as the first step after the failure of conventional oxygen therapy8, and taking into account the availability of NIRS devices at each centre. NIRS treatments were applied continuously for at least 48h while controlling oxygen delivery to obtain a target oxygen saturation measured by pulse oximetry (SpO2) of 9296%21. The discrepancy between these results and ours may be due to differences in the characteristics of the patients included. This study was approved by the institutional review board of AHCFD, which waived the requirement for individual patient consent for participation. Although our study was not designed to assess the effectiveness of any of the above medications, no significant differences between survivors and non-survivors were observed through bivariate analysis. But there are reports that people with COVID-19 who are put on ventilators stay on them for days or weeksmuch longer than those who require ventilation for other reasonswhich further reduces . PLoS ONE 16(3): Autopsy studies have highlighted the presence of microthrombi in the lung circulation as evidence of the pathophysiology of COVID pneumonia, similar to what has been described in ARDS with DIC [23, 24]. Second, we must be cautious before extrapolating our results to other nonemergency situations. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Chronic conditions were frequent (35% of the sample had a Charlson comorbidity index2) and did not differ between NIRS treatment groups, except for sleep apnea (more common in the NIV-treated group, Table 1 and Table S1). Average PaO2/FiO2 during hospitalization was lower in non-survivors [167 (IQR 132.7194.1)] versus survivors [202 (IQR 181.8234.4)] p< 0.001. 2 Clinical types included (1) mild cases in which the patient had mild clinical symptoms and no imaging findings of pneumonia; (2) common cases in which the patient had fever, respiratory symptoms, and imaging manifestations of . Due to some of the documented shortcomings of PCR testing early in this pandemic, some patients required more than one test to document positivity. The high mortality rate, especially among elderly patients with some . In patients requiring MV, mortality rates have been reported to be as high as 97% [9]. Bellani, G. et al. 372, 21852196 (2015). The coronavirus behind the pandemic causes a respiratory infection called COVID-19. Nevertheless, we do not think it may have influenced our results, because analyses were adjusted for relevant treatments such as systemic corticosteroids40 and included the time period as a covariate. Between April 2020 and May 2021, 1,273 adults with COVID-19-related acute hypoxemic respiratory failure were randomized to receive NIV (n = 380), HFNC oxygen (n = 418), or conventional oxygen therapy (n = 475). We compared patient characteristics and demographics between pre-pandemic and pandemic periods, with data collected from January 2018 to March 2022. The virus, named SARS-CoV-2, gets into your airways and can make it. 56, 2001692 (2020). For people hospitalized with covid-19, 15-30% will go on to develop covid-19 associated acute respiratory distress syndrome (CARDS). Our study demonstrates the possibility of better outcomes for COVID-19 associated with critical illness, including COVID-19 patients requiring mechanical ventilation. Standardized respiratory care was implemented favoring intubation and MV over non-invasive positive pressure ventilation. Inspired oxygen fraction achieved with a portable ventilator: Determinant factors. Leonard, S. et al. Patients tend to overestimate their chances of surviving arrest by, on average, 60.4%. J. CAS The average survival-to-discharge rate for adults who suffer in-hospital arrest is 17% to 20%. it is possible that the poor survival in patients with COVID-19 reported in the study from Wuhan are in part, because the hospital was severely overwhelmed with patients with COVID-19 and . As the COVID-19 surge continues, Atrium Health has a record-breaking number of patients in the intensive care unit (ICU) and on ventilators. Eur. The International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC). Roughly 2.5 percent of people with COVID-19 will need a mechanical ventilator. About half of COVID-19 patients on ventilators die, according to a 2021 meta-analysis. Additionally, anesthesia machines being used for prolonged periods as ICU ventilators may present challenges pertaining to scavenging, excessive inhalational agent consumption, and . Intensivist were not responsible for more than 20 patients per 12 hours shift. The truth is that 86% of adult COVID-19 patients are ages 18-64, so it's affecting many in our community. Stata Statistical Software: Release 16. Franco, C. et al. Centers that do a lot of ECMO, however, may have survival rates above 70%. PubMedGoogle Scholar. Grieco, D. L. et al. As doctors have gained more experience treating patients with COVID-19, they've found that many can avoid ventilationor do better while on ventilatorswhen they are turned over to lie on their stomachs. In the stratified analysis of our cohort, planned a priori, patients with a PaO2/FIO2 ratio above 150 responded similarly to HFNC and NIV treatments, suggesting that the severity of the hypoxemia might predict the success of NIV, as previously reported in non-COVID patients4,28,29. This secondary analysis of an ongoing adaptive platform trial examines the effect of multiple interventions for critically ill adults with COVID-19 on longer-term outcomes. Tocilizumab was utilized in 56 (43.7%), and 37 (28.2%) were enrolled in blinded placebo-controlled studies aimed at the inflammatory cascade. HFNC was not used during breaks in the NIV or CPAP groups due to the limited availability of devices in the first wave of the pandemics. Of these 9 patients, 8 were treated with veno-venous ECMO (survival 7 of 8) and one with veno-arterial-venous ECMO (survival 1 of 1). 56, 1118 (2020). It was populated by many patients who were technically Covid-19 survivors because they were no longer infected with SARS-CoV-2. Physiologic effects of high-flow nasal cannula in acute hypoxemic respiratory failure. ISGlobal acknowledges support from the Spanish Ministry of Science and Innovation through the Centro de Excelencia Severo Ochoa 20192023 Program (CEX2018-000806-S), and from the Generalitat de Catalunya through the CERCA Program. KaplanMeier curves described the crude event-free rate in each NIRS group and were compared by means of the log-rank test. Our study demonstrates an important improvement in mortality of patients with severe COVID-19 who required ICU admission and MV in comparison to previous observational reports and emphasizes the importance of standard of care measures in the management of COVID-19. The 12 coronavirus patients who were put on ventilator support at the Government Rajindra Hospital in Patiala ended up succumbing to the disease. Third, crossovers could have been responsible for differences observed between NIRS treatments but their proportion was small (12%) and our results did not change when these patients were excluded. Children with acute lymphoblastic leukemia living in US-Mexico border regions had worse 5-year survival rates compared with children living in other parts of Texas, a recent study found. Baseline demographic and clinical characteristics of patients are summarized in Tables 1 and 2 respectively. Lower positive end expiratory pressure (PEEP) were observed in survivors [9.2 (7.710.4)] vs non-survivors [10 (9.112.9] p = 0.004]. COVID-19 patients also . Of the 1511 inpatients with CAP, COVID-19 was the leading cause, accounting for 27%. How Long Do You Need a Ventilator? & Cecconi, M. Critical care utilization for the COVID-19 outbreak in Lombardy, Italy: Early experience and forecast during an emergency response. J. Most patients were male (72%), and the mean age was 67.5years (SD 11.2). More studies are needed to define the place of treatment with helmet CPAP or NIV in respiratory failure due to COVID-19, together with other NIRS strategies. Recommended approaches to minimize aerosol dispersion of SARS-CoV-2 during noninvasive ventilatory support can cause ventilator performance deterioration: A benchmark comparative study. In conclusion, the present real-life study shows that, in the context of the pandemic and outside the intensive care unit setting, noninvasive ventilation for the treatment of hypoxemic acute respiratory failure secondary to COVID-19 resulted in higher treatment failure than high-flow oxygen or CPAP. Docherty, A. PLOS ONE promises fair, rigorous peer review, Association of noninvasive oxygenation strategies with all-cause mortality in adults with acute hypoxemic respiratory failure: A systematic review and meta-analysis. It's calculated by dividing the number of deaths from the disease by the total population. In patients with mild-moderate hypoxaemia, CPAP, but not NIV, treatment was associated with reduced outcome risk compared to HFNC (Table S5). A multivariate logistic regression model identified renal replacement therapy as a significant predictor of mortality in this dataset (p = 0.006) (Table 5). This study has some limitations. While patients over 80 have a low survival rate on a ventilator, Rovner says someone who is otherwise mostly healthy with rapidly progressing COVID-19 in their 50s, 60s or 70s would be recommended . What is the survival rate for ECMO patients? In fact, it is reassuring that the application of well-established ARDS and mechanical ventilation strategies can be associated with mortality and outcomes comparable to non-COVID-19 induced sepsis or ARDS. Lower age, higher self-sufficiency, less severe initial COVID-19 presentation, and the use of vitamin K antagonists were associated with a lower chance of in-hospital death, and at multivariable analysis, AF was a prevalent and severe condition in older CO VID-19 patients. Unfortunately, tidal volume measurements during NIV were not available in our study to support or reject this hypothesis. Care 17, R269 (2013). Curr. Excluding these patients showed no relevant changes in the associations observed (Table S9). Acquisition, analysis or interpretation of data: S.M., A.-E.C., J.S., M.P., I.A., T.M., M.L., C.L., G.S., M.B., P.P., J.M.-L., J.T., O.B., A.C., L.L., S.M., E.V., E.P., S.E., A.B., J.G.-A. Although the effectiveness and safety of this regimen has been recently questioned [12]. Only 9 of 131 ICU patients, received extracorporeal membrane oxygenation (ECMO), with most of them surviving (8, 88%). Joshua Goldberg, ICU outcomes in patients with COVID-19 and predicted mortality. In the only available study (also observational) comparing NIV, HFNC and CPAP outside the ICU16, conducted in Italy, the authors did not find differences between treatments in mortality or intubation at 30days. Convalescent plasma was administered in 49 (37.4%) patients. Vincent Hsu, Thille, A. W. et al. Mayo Clinic is on the front line leading COVID-19-focused research efforts. Care Med. The first case of COVID-19 in HK was confirmed on 23 Jan 2020. Patients were also enrolled in institutional review board (IRB) approved studies for convalescent plasma and other COVID-19 investigational treatments. Since then, a RCT has shown that steroids in doses even lower than what we used (6 mg a day for up to 10 days) improve survival with an NNT of 35 (ARR 2.7%) in all patients requiring supplemental oxygen [35]. ISSN 2045-2322 (online). At age 53 with Type 2 diabetes and a few extra pounds, my chance of survival was far less than 50 percent. Before/after observational study in a mixed intensive care unit (ICU) of a university teaching hospital. | World News Baseline demographic characteristics of the patients admitted to ICU with COVID-19. In patients 80 years old with asystole or PEA on mechanical ventilation, the overall rate of survival was 6%, and survival with CPC of 1 or 2 was 3.7%. Google Scholar. J. Respir. The main difference in respect to our study was the better outcomes of CPAP compared with HFNC. Most of these patients admitted to ICU, will finally require invasive mechanical ventilation (MV) due to diffuse lung injury and acute respiratory distress syndrome (ARDS).