Herein we present a report of four cases of severe type II respiratory failure that had contraindications both to conventional non-invasive ventilation and to endotracheal intubation. In all four cases, we successfully used a high-flow nasal oxygen device as a rescue device, with very reassuring outcomes.

(1) Background: High-flow nasal therapy (HFNT) has shown several benefits in addressing respiratory failure. However, the quality of evidence and the guidance for safe practice are lacking. This survey aimed to understand HFNT practice and the needs of the clinical community to support safe practice. (2) Method: A survey questionnaire was developed and distributed to relevant healthcare professionals through national networks in the UK, USA and Canada; responses were collected between October 2020 and April 2021. (3) Results: In the UK and Canada, HFNT was used in 95% of hospitals, with the highest use being in the emergency department. HNFT was widely used outside of a critical care setting. HFNT was mostly used to treat acute type 1 respiratory failure (98%), followed by acute type 2 respiratory failure and chronic respiratory failure. Guideline development was felt to be important (96%) and urgent (81%). Auditing of practice was lacking in 71% of hospitals. In the USA, HFNT was broadly similar to UK and Canadian practice. (4) Conclusions: The survey results reveal several key points: (a) HFNT is used in clinical conditions with limited evidence; (b) there is a lack of auditing; (c) it is used in wards that may not have the appropriate skill mix; and (d) there is a lack of guidance for HFNT use.

The first confirmed case of COVID-19 in Quebec, Canada, occurred at Verdun Hospital on February 25, 2020. A month later, a localized outbreak was observed at this hospital. We performed tiled amplicon whole genome nanopore sequencing on nasopharyngeal swabs from all SARS-CoV-2 positive samples from 31 March to 17 April 2020 in 2 local hospitals to assess viral diversity (unknown at the time in Quebec) and potential associations with clinical outcomes. We report 264 viral genomes from 242 individuals–both staff and patients–with associated clinical features and outcomes, as well as longitudinal samples and technical replicates. Viral lineage assessment identified multiple subclades in both hospitals, with a predominant subclade in the Verdun outbreak, indicative of hospital-acquired transmission. Dimensionality reduction identified two subclades with mutations of clinical interest, namely in the Spike protein, that evaded supervised lineage assignment methods–including Pangolin and NextClade supervised lineage assignment tools. We also report that certain symptoms (headache, myalgia and sore throat) are significantly associated with favorable patient outcomes. Our findings demonstrate the strength of unsupervised, data-driven analyses whilst suggesting that caution should be used when employing supervised genomic workflows, particularly during the early stages of a pandemic.

Background: Awake prone positioning (APP) has been advocated to improve oxygenation and prevent intubations of patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). This paper aims to synthesize the available evidence on the efficacy of APP.Methods: We performed a systematic review and meta-analysis of observational studies to compare oxygenation parameters in-hospital intubation rate in patients treated with APP or with standard care.Results: A total of 46 published and 4 unpublished observational studies that included 2994 patients were included. APP was associated with significant improvement of various oxygenation parameters in 19 studies (n=381) that reported this outcome. The intubation rate was 27% (95%CI, 19 to 37%) in the 870 patients treated with APP, as compared to 30% (95%CI, 20 to 42%) in the 852 patients treated with usual care (p=0.71).Conclusions: On the basis of the available evidence, it is not possible to demonstrate efficacy of APP for patients with COVID-19 acute respiratory failure, as assessed by the need for invasive ventilation. Routine implementation of APP outside of a clinical trial is not supported by current evidence. Randomized controlled clinical studies are urgently needed to definitively assess the utility of APP in these patients.Registered on PROSPERO on August 3d, 2020, CRD42020201947.